Sexual Safety of Mental Health Consumers Guidelines · Sexual Safety of Mental Health Consumers...

Sexual Safety of Mental Health Consumers Guidelines

Summary The purpose of these guidelines is to - Support mental health services to meet their responsibilities in relation to the sexual safety of mental health consumers through theprovision of practical advice and strategies; - Promote sexual safety to key stakeholders – health staff and managers, consumers and their families and carers; - Clearly outline the information consumers and their families and carers should receive about their rights and obligations in relation to the sexual safety of consumers;and- Improve collaboration and strengthen relationships between mental health services and Sexual Assault Services.

Document type Guideline

Document number GL2013_012

Publication date 12 November 2013

Author branch Mental Health

Branch contact 02 9391 9306

Review date 30 May 2020

Policy manual Patient Matters

File number H13/72517

Previous reference N/A

Status Review

Functional group Clinical/Patient Services - Mental Health

Applies to Local Health Districts, Board Governed Statutory Health Corporations, Chief Executive Governed Statutory Health Corporations, Specialty Network Governed Statutory Health Corporations, Community Health Centres, NSW Ambulance Service, Ministry of Health, Public Hospitals

Distributed to Public Health System, Ministry of Health

Audience All Staff;Clinical;Allied Health;Nursing;Emergency Departments

Guideline

Secretary, NSW Health

GUIDELINE SUMMARY

GL2013_012 Issue date: November-2013 Page 1 of 2

SEXUAL SAFETY OF MENTAL HEALTH CONSUMERS GUIDELINES

PURPOSE The Sexual Safety of Mental Health Consumers Guidelines provide practical information, advice and strategies to help mental health services maintain the sexual safety of mental health consumers and respond appropriately to incidents that breach or compromise this safety. Sexual safety refers to the recognition, maintenance and mutual respect of the physical (including sexual), psychological, emotional and spiritual boundaries between people.

These Guidelines should be read in conjunction with Policy Directive PD 2013_038, which mandates the minimum requirements that must be met in this regard.

KEY PRINCIPLES The key principles in these Guidelines, and the associated Policy Directive, are listed below.

1. All mental health consumers are entitled to be sexually safe.

2. Mental health services take appropriate action to prevent and appropriately respond to sexual safety incidents.

3. Mental health services support mental health consumers to adopt practices and behaviours that contribute to their sexual safety, both within the mental health service environment and within the community.

4. Mental health services develop individual sexual safety standards appropriate for their particular setting, in collaboration with all members of the service including staff, consumers, carers, clinicians, advocates etc.

5. The physical environment of the mental health service takes account of the need to support the sexual safety of mental health consumers in its layout and use, particularly in regard to gender sensitivity.

6. Mental health consumers, and their families, carers and advocates, are given access to clear information regarding the consumer’s rights, advocacy services, and appropriate mechanisms for complaints and redress regarding sexual safety issues.

7. Mental health service staff and clinicians foster a compassionate and open culture that encourages reporting of incidents relating to the sexual safety of mental health consumers.

8. Disclosures from mental health consumers about incidents that compromise or breach their sexual safety are taken seriously and addressed promptly and empathetically, regardless of the identity or affiliation of the alleged perpetrator, and with the utmost regard for the complainant’s privacy and dignity, past trauma, cultural background, gender, religion, sexual identity, age and the nature of their illness.

9. Mental health service staff are provided with training and education to enable them to:

a. Effectively promote strategies to support sexual safety and prevent sexual assault and harassment

b. Respond appropriately and sensitively to sexual safety issues involving mental health consumers, both within the service environment and within the community

c. Integrate trauma-informed care principles into all aspects of treatment.

GUIDELINE SUMMARY

GL2013_012 Issue date: November-2013 Page 2 of 2

10. Mental health consumers are supported to access education to enable them to:

a. Effectively recognise and respond to behaviours, both their own and other people’s, that may compromise or breach their own or another person’s sexual safety

b. Develop self-protective behaviours

c. Establish and maintain good sexual health.

USE OF THE GUIDELINE These Guidelines apply to NSW Health services providing specialist mental health care in all settings including acute inpatient, non-acute inpatient, rehabilitation and community,and staff working for such services.

Where a service has a mix of acute and non-acute consumers in the one unit or facility, it is the responsibility of the service to ensure they implement these Guidelines and the associated Policy Directive in a way that addresses this mix.

The scope of the Guidelines does not extend to providing practical and detailed guidance about how services can best manage issues relating to sexual activity involving consumers. Services are encouraged to develop their own local policies and protocols in relation to this area, being mindful of the policy approach advocated within these Guidelines regarding the right of consumers to express their sexuality safely and respectfully in the appropriate settings.

The Policy Directive outlines a number of Responsibilities and Minimum Requirements for:

• all Mental Health Services, (pg 11)

with additional Responsibilities and Minimum Requirements specific to:

• acute inpatient mental health settings (pg 13)

• non-acute and residential mental health settings (pg 14)

• community mental health settings (pg 15).

Implementation will be staged over a two year period, and must be completed by June of 2014.

Implementation by individual services should be monitored by each Local Health District via the Individual Service Implementation Monitoring Form at Appendix IV of the associated Policy Directive.

REVISION HISTORY Version Approved

by Amendment notes

November 2013 (GL2013_012)

Director General

Inclusion of all mental settings, education, prior history, gender sensitive practices, safe sex practices, respected disclosure, trauma informed care approach and identification of specific incident types.

January 2005 (GL2005_049)

Director General

New policy.

ATTACHMENTS 1. Sexual Safety of Mental Health Consumers: Guidelines

Sexual Safety of Mental Health Consumers

GuidelinesPractical information, advice and strategies to help mental health

services maintain the sexual safety of mental health consumers

NSW MINISTRY OF HEALTH

73 Miller Street

NORTH SYDNEY NSW 2060

Tel. (02) 9391 9000

Fax. (02) 9391 9101

TTY. (02) 9391 9900

www.health.nsw.gov.au

This work is copyright. It may be reproduced in whole or in part for study

training purposes subject to the inclusion of an acknowledgement of the source.

It may not be reproduced for commercial usage or sale. Reproduction for

purposes other than those indicated above requires written permission from the

NSW Ministry of Health.

© NSW Ministry of Health 2013

GL2013_012

SHPN: (MHDAO) 120421

ISBN: 978-1-74187-865-3

For further copies of this document please contact:

Better Health Centre – Publications Warehouse

PO Box 672

North Ryde BC, NSW 2113

Tel. (02) 9887 5450

Fax. (02) 9887 5452

Further copies of this document can be downloaded from the

NSW Ministry of Health website www.health.nsw.gov.au

November 2013

Sexual Safety of Mental Health Consumers Guidelines NSW HealtH PaGe 1

Contents

1. Introduction ........................................... 31.1 Definitions ............................................... 3

1.2 Principles of care ..................................... 5

1.3 Scope ..................................................... 5

1.3.1 Settings ................................................ 5

1.3.2 Focus .................................................... 6

1.3.3 Population groups ................................ 6

1.4 Purpose and intended outcomes .............. 6

1.5 Background ............................................. 7

1.6 Development process ............................. 7

1.6.1 Expert practitioners .............................. 7

1.6.2 Literature review ................................... 7

1.6.3 Consultation ......................................... 7

2. Sexual safety and mental health ............ 92.1 Defining sexual safety .............................. 9

2.2 The importance of sexual safety for

people with a mental illness ..................... 9

2.3 Sexual safety incident types ................... 10

2.3.1 Sexual assault and harassment ........... 10

2.3.2 Consensual sexual activity in an

inappropriate context or setting ..........11

2.3.3 Sexually disinhibited behaviour ............12

2.4 Rights and responsibilities regarding

sexual safety ...........................................12

2.4.1 Mental health consumers in all

settings have the right to: ....................12

2.4.2 All members of a mental health

service have the right to: .....................13

2.4.3 Mental health services in all settings

have a responsibility to: .......................13

2.4.4 All members of a mental health

service have a responsibility to: ............13

2.5 Relevant legislation, standards/rights

and policies ............................................13

2.5.1 Legislation ...........................................13

2.5.2 Standards and rights ........................... 14

2.5.3 Associated NSW Health policies ......... 14

3. Fostering a culture that supports sexual safety .......................................... 163.1 Training and education .......................... 16

3.1.1 Supporting mental health staff .......... 16

3.1.2 Empowering consumers .....................17

3.1.3 Recognising families, friends

and carers .......................................... 18

3.2 Promoting sexual safety .........................19

3.3 The importance of collaboration ............19

3.3.1 Consumers ......................................... 19

3.3.2 Families and carers ............................. 20

3.3.3 General practitioners (GPs) ................. 20

3.3.4 NSW Health Sexual Assault Services ... 20

3.3.5 NSW Police Force................................ 21

3.3.6 Other agencies ................................... 21

3.3.7 Partner programs/Community

managed organisations (CMOs) .......... 22

4. Preventing a Sexual Safety Incident ... 244.1 Sexual assault and harassment ............... 24

4.1.1 Assessing vulnerability ....................... 24

4.1.2 Taking an appropriate sexual assault

and harassment history ...................... 24

4.1.3 Recognising offender tactics ............... 26

4.1.4 The role of gender sensitivity .............. 26

4.1.5 Practical security measures ................. 27

4.1.6 Maintaining professional boundaries . 28

4.2 Consensual sexual activity in an

inappropriate context or setting ............. 30

4.2.1 Sexual safety standards ...................... 30

4.2.2 Addressing sexuality needs ................ 30

4.3 Sexually disinhibited behaviour ............. 31

NSW HealtH Sexual Safety of Mental Health Consumers Guidelines

5. Responding to a Sexual Safety Incident .................................................. 35

5.1.1 When there is disclosure or

acknowledgement of sexual assault

or harassment .................................... 35

5.1.2 When sexual assault or harassment

is suspected but not disclosed .............41



5.2.1 Understanding consent and

capacity .............................................. 43

5.2.2 Staff attitudes .................................... 44

5.3 Sexually disinhibited behaviour .............. 44

6. Reporting and Recording .................... 476.1.1 Reporting ............................................. 47

6.1.2 Recording .......................................... 49



6.2.1 Reporting .......................................... 50

6.2.2 Recording ........................................... 50

6.3 Sexually disinhibited behaviour ..............51

6.3.1 Reporting ...........................................51

6.3.2 Recording ............................................51

7. Highly vulnerable groups ..................... 527.1 Consumers who are Aboriginal and

Torres Strait Islander ............................. 52

7.2 Consumers who are children or

young people ........................................ 53

7.3 Consumers from a culturally and

linguistically diverse background ............ 54

7.4 Consumers with Intellectual

Disability ................................................ 54

7.5 Gay, Bisexual, Lesbian and

Transgender Consumers ........................ 55

7.6 Older consumers .................................. 56

Appendices .................................................. 57Appendix A – Example Sexual Safety Standards

of Behaviour ...................................... 58

Appendix B – Charter of Victims Rights .................... 59

Appendix C – Relevant standards and the

legislative framework ..........................61

Appendix D – Information about support options

for consumers who have experienced

sexual assault .................................... 64

Appendix E – Information about reporting to

Police for consumers who have

experienced sexual assault .................. 65

Appendix F – Example posters on accessing

support............................................... 66

Appendix G – Sexual Assault Screening Tool ........... 68

Appendix H – Examples of sexualised behaviour

by healthcare professionals towards

consumers or their carers ................... 70

Appendix I – Responding to a disclosure of sexual

assault – key actions ........................... 71

Appendix J – Responding to a disclosure of recent

sexual assault – quick checklist ............ 73

Appendix K – Follow up medical exams required

when a person has been sexually

assaulted .............................................74

Appendix L – Reporting process for an incident

of sexual assault ............................... 75

Appendix M – Information about Managing

Disinhibited Behaviour ....................... 76

References .................................................... 77


SECTION 1

Introduction

1.1 Definitions

For the purpose of this resource, the following definitions apply.

Term Meaning

Consensual sexual activity

Sexual activity that occurs after mutual sexual consent has been provided by those involved. Also see ‘sexual consent’.

Consumer Someone with a mental illness or disorder that uses a mental health service.

Continuum of sexual violence

A range or succession of related sexual behaviours involving intrusion and violation, extending from unwanted sexual comments to unwanted touching of a sexual nature and rape.

Gender sensitive practices

The different needs of men and women are considered in all aspects of service planning and service delivery.

Intra-familial sexual assault

Any sexual activity between closely related persons, normally within the immediate family, which is either illegal or socially forbidden. Immediate family can include a parent, son, daughter, sibling (including a half-brother or half-sister), grandparent or grandchild, being such a family member from birth.

Informed decision A decision made by a consumer who understands the nature, extent, or probable consequences of the decision, and can make a rational evaluation of the risks and benefits of alternatives. The decision cannot be considered informed unless the consumer is mentally competent and the decision made voluntarily.

Masturbation The stimulation of one’s own genital organs, usually to orgasm, by manual contact or means other than sexual intercourse.

Mental health service Any establishment or any unit of an establishment that has the primary function of providing mental health care.

Mental health workers/staff

Any person working in a permanent, temporary, casual, term appointment or honorary capacity within a NSW Health mental health organisation. This includes volunteers, consumer advocates, contractors, visiting practitioners, students, consultants and researchers performing work within NSW Health facilities.

Mentally competent The capacity to understand information, make decisions, and act reasonably.

Perpetrator/offender Someone who has breached the sexual safety of a consumer.

Sexual abuse See ‘sexual assault’.

Sexual activity Activity of a sexual nature with oneself (masturbation) or another (sexual touching, sexual intercourse, oral sex).

Sexual assault Sexual assault occurs when:

■ a person is forced, coerced or tricked into sexual acts against their will or without their consent, or

■ a child or young person under 16 years of age is exposed to sexual activities, or

■ a young person over 16 and under 18 years of age is exposed to sexual activities by a person with whom they have a relationship of ‘special care’ e.g. step-parent, guardian, foster parent, health practitioner, employer, teacher, coach, priest, etc.

Sexual coercion The practice of gaining involuntary permission to gain access to a person for the purposes of sexual gratification. Methods used include psychological inducements and physical force e.g. trickery, bribes, inducements (money, food, drugs, etc), offers of care, love, protection, meeting emotional needs, threats, making captive. Coercion is intrinsic in child sexual assault and to the exploitation of other vulnerable persons.


Term Meaning

Sexual consent To give permission for something of a sexual nature to happen, agree to do something of a sexual nature, or accept something of a sexual nature proposed or desired by another. Consent can only be considered valid if:

■ the consumer is an adult (16 years of age and over) that is mentally competent to consent, and

■ where the consumer is between 16 and 18 years of age, there is no ‘special care’ relationship with the person to whom they have consented e.g. step-parent, guardian, foster parent, health practitioner, employer, teacher, coach, priest, etc, and

■ the consent is given voluntarily and without coercion.

Consent must be provided each time and not be based on prior behaviour.

Sexually disinhibited behaviour

Poorly controlled behaviour of a sexual nature, where sexual thoughts, impulses or needs are expressed in a direct or disinhibited way, such as in inappropriate situations; at the wrong time; or with the wrong person.

Sexual harassment Unwelcome conduct of a sexual nature which makes a person feel offended, humiliated and/or intimidated where that reaction is reasonable in the circumstances. Can involve physical, visual, verbal or non-verbal conduct.

Sexual health A state of physical, emotional, mental and social well-being related to sexuality, including the absence of disease, dysfunction or infirmity; a positive and respectful approach to sexuality and sexual relationships; the possibility of having pleasurable and safe sexual experiences, free from coercion, discrimination and violence, and; respect for the sexual rights of all persons. (World Health Organisation)

Sexual safety The recognition, maintenance and mutual respect of the physical, psychological, emotional and spiritual boundaries between people.

Sexual safety incident The term used to refer to an incident that breaches or compromises the sexual safety of a consumer, and which is recognised as either sexual assault or harassment, consensual sexual activity in an inappropriate setting or sexually disinhibited behaviour.

Sexual violence See ‘sexual assault’.

‘Special care’ relationship

A relationship that exists between a young person 16–18 years of age and a person in a position of influence or authority over that young person. This group could include:

■ step-parents

■ guardians

■ foster parents

■ health practitioners

■ employers

■ teachers

■ sporting coaches

■ priests

Survivor A person who has been sexually assaulted or has experienced sexual harassment. Also see ‘victim’.

Trauma informed care Mental health treatment that is directed by:

■ a thorough understanding of the profound neurological, biological, psychological and social effects of trauma and violence on the individual; and

■ an appreciation for the high prevalence of traumatic experiences in persons who receive mental health services. (Jennings, 2004)

Victim A person who has been sexually assaulted or has experienced sexual harassment. Also see ‘survivor’.


1.2 Principles of care

The following principles have been developed to provide

a clear foundation for the establishment and maintenance

of the sexual safety of consumers in all mental health

service settings.

1. All mental health consumers are entitled to be

sexually safe.

2. Mental health services take appropriate action to

prevent and appropriately respond to sexual safety

incidents.

3. Mental health services support mental health

consumers to adopt practices and behaviours that

contribute to their sexual safety, both within the

mental health service environment and within the

community.

4. Mental health services develop individual sexual safety

standards appropriate for their particular setting, in

collaboration with all members of the service – staff,

consumers, carers, clinicians, advocates etc.

5. The physical environment of the mental health service

takes account of the need to support the sexual

safety of mental health consumers in its layout and

use, particularly in regard to gender sensitivity.

6. Mental health consumers, and their families, carers

and advocates, are given access to clear information

regarding the consumer’s rights, advocacy services,

and appropriate mechanisms for complaints and

redress regarding sexual safety issues.

7. Mental health service staff and clinicians foster a

compassionate and open culture that encourages

reporting of incidents relating to the sexual safety of

mental health consumers.

8. Disclosures from mental health consumers about

incidents that compromise or breach their sexual

safety are taken seriously and addressed promptly and

empathetically, regardless of the identity or affiliation

of the alleged perpetrator, and with the utmost

regard for the complainant’s privacy and dignity, past

trauma, cultural background, gender, religion, sexual

identity, age and the nature of their illness.

9. Mental health service staff are provided with training

and education to enable them to:

a. Effectively promote strategies to support sexual

safety and prevent sexual assault and harassment;

and

b. Respond appropriately and sensitively to sexual

safety issues involving mental health consumers,

both within the service environment and within

the community; and

c. Integrate trauma-informed care principles into all

aspects of treatment.

10. Mental health consumers are supported to access

education to enable them to:

a. Effectively recognise and respond to behaviours,

both their own and other people’s, that may

compromise or breach their own or another

person’s sexual safety;

b. Develop self-protective behaviours; and

c. Establish and maintain good sexual health.

1.3 Scope

1.3.1 SettingsThese guidelines apply to NSW Health services providing

specialist mental health care in all settings – acute

inpatient, non-acute inpatient, rehabilitation and

community – and staff working for such services.

The guidelines outline the recommended policy approach

to maintaining the sexual safety of consumers and

responding appropriately to incidents that breach or

compromise this safety. They should be read in

conjunction with Policy Directive PD 2013_038, which

mandates the minimum requirements that must be met in

this regard.

It should be noted that where a service has a mix of acute

and non-acute consumers in the one unit or facility, it is

the responsibility of the service to ensure they implement

these guidelines and the associated Policy Directive in a

way that addresses this mix.


1.3.2 FocusThe focus of these guidelines is sexual safety for

consumers. Sexual safety refers to the recognition,

maintenance and mutual respect of the physical (including

sexual), psychological, emotional and spiritual boundaries

between people. Advice regarding how to manage

incidents of sexual assault or harassment that do not

involve consumers of the service can be accessed from a

range of NSW Health policies, including Complaints

Management Policy PD2006_073 and Criminal

allegations, charges and convictions against employees

PD2006_026. See Section 2.5.3 Associated NSW Health

Policies for further information.

The scope of these guidelines does not extend to

providing practical and detailed guidance about how

services can best manage issues relating to sexual activity

involving consumers. Services are encouraged to develop

their own local policies and protocols in relation to this

area, being mindful of the policy approach advocated

within these guidelines regarding the right of consumers

to express their sexuality safely and respectfully in the

appropriate settings.

However, NSW Health recognises that good sexual health

and healthy and respectful sexual relationships are important

and intrinsically linked to sexual safety. For this reason,

information about sexual health issues is included where

appropriate, and sexuality and sexual health education for

consumers and training for staff is acknowledged as an

important component of an overall sexual safety strategy.

1.3.3 Population groupsInformation specific to the needs of consumers who are

particularly vulnerable, including children and young

people, is provided in Section 7.

At relevant points throughout the document advice is

also provided around the responsibilities of service

providers in relation to the safety, welfare and wellbeing

of the children and young people who may be in contact

with or in the care of consumers using an adult mental

health care service.

The reforms to the NSW child protection system under

Keep Them Safe: A Shared Approach to Child Wellbeing

2009–2014 mandates that every health worker that

comes into contact with a child or young person has

a responsibility to protect their health, safety, welfare

and wellbeing.

The NSW Health Frontline Policies and Procedures for

Child Protection and Wellbeing (revised procedures being

finalised at the time of printing) operationalise the

responsibilities of NSW Health under the Children and

Young Persons (Care and Protection) Act 1998 and are

relevant to all health workers and services, including

those providing services to adult clients who may be

parents or carers.

1.4 Purpose and intended outcomes

The purpose of these guidelines is to:

■ Support mental health services to meet their

responsibilities in relation to the sexual safety of

mental health consumers through the provision of

practical advice and strategies.

■ Promote sexual safety to key stakeholders – health

staff and managers, consumers and their families

and carers.

■ Increase the awareness of all stakeholders regarding

the importance of:

– Training for staff to enable them to prevent and

respond to sexual safety incidents; and

– Access to education for consumers to enable them

to recognise behaviours that could compromise or

breach their sexual safety, develop self-protective

behaviours and attain good sexual health.

■ Clearly outline the information consumers and their

families and carers should receive about their rights

and obligations in relation to the sexual safety of

consumers.

■ Improve collaboration and strengthen relationships

between mental health services and Sexual Assault

Services.

The intended outcomes of the guidelines are:

■ Prioritisation of the sexual safety of mental health

consumers by mental health services.

■ An increase in the number of mental health staff

who are appropriately trained to manage sexual

safety issues.

■ Reduction of the number of sexual safety incidents in

inpatient and rehabilitation units.

■ Greater promotion of the responsibilities of mental

health services in relation to sexual safety, including their

role in supporting consumers within the community.

■ Awareness by mental health staff of the benefits of


helping consumers to access education on sexuality

and sexual health issues.

■ Awareness by consumers and their families and carers

of the rights and responsibilities of consumers

regarding their sexual safety.

■ A greater sense of confidence within the community

regarding the sexual safety of mental health consumers.

■ Stronger collaboration between Sexual Assault

Services and mental health services.

■ Consideration of prior sexual trauma of consumers

within the treatment context.

1.5 Background

These guidelines supersede the Guidelines for the

Promotion of Sexual Safety in NSW Mental Health

Services, which were first released in 1999 and revised

and re-released in 2005.

Since that time, feedback to the Mental Health and Drug

and Alcohol Office (MHDAO) and the Clinical Advisory

Council (CAC) has indicated that the guidelines in their

current format may not have been providing the

appropriate level of support to mental health service staff

regarding how to respond to sexual safety issues.

Points raised in relation to the guidelines included:

■ Insufficient information provided regarding how staff

should respond to particular sexual safety issues (e.g.

prior sexual assault trauma; consensual sex;

identifying offender tactics etc)

■ Limited scope – only applicable to inpatient units

■ Did not take account of the differing needs of

particular groups, such as children and adolescents,

older people, Gay, Lesbian, Bisexual and Transgender

(GLBT) people, Aboriginal people, culturally and

linguistically diverse people etc.

■ Out of date information regarding reporting

procedures, including the use of mental health clinical

documentation (formerly MH-OAT)

In response to this, CAC agreed to review of the

guidelines with a view to improving their effectiveness,

and this action was endorsed by the Mental Health

Program Council (MHPC). This also provided an

opportunity to develop a Policy Directive to improve

consistency across services and clarity around

responsibilities as well as to review and revise the current

format and content of the sexual safety training provided

to mental health services.

As the new guidelines are about promoting sexual safety,

and preventing and appropriately responding to sexual

safety incidents in all settings, the title has been changed

to Sexual Safety of Mental Health Consumers to

reflect this.

1.6 Development process

1.6.1 Expert practitionersA range of expert practitioners provided input and

guidance throughout the development process, including

individuals from the following sectors:

■ Sexual assault prevention and response education

■ Sexual Assault Services

■ Community mental health

■ Inpatient mental health

■ Mental health rehabilitation

■ Violence prevention

Consumer representatives from the NSW Consumer

Advisory Group – Mental Health (Inc) also contributed to

the development of the framework and content of this

document.

1.6.2 Literature reviewA literature review was undertaken, primarily utilising

electronic research methods, regarding sexual safety

issues within a mental health service context that

encompassed national and international literature.

The review also identified strategies and recommendations

for improving sexual safety in mental health services and

examples of tools, guidelines and policies that would

support better management of sexual safety issues

for consumers.

This information, along with additional research

undertaken around the importance of sexual ethics and

sexual health information for consumers in preventing

sexual assault and harassment, provided a framework for

development of the guidelines.

1.6.3 ConsultationConsultation was considered a critical component in the

development of the guidelines.


A reference group, comprised of key stakeholder groups

and individuals, provided regular feedback to the project

throughout the development process. Sectors represented

included:

■ Forensic mental health

■ Children and adolescent mental health

■ Older people’s mental health

■ Carers and families

■ Multicultural mental health

■ Aboriginal mental health

■ Mental health consumers

■ Patient safety

Further consultation was also undertaken with the

following stakeholder groups at fundamental stages:

■ ACON

■ Aboriginal Health and Medical Research Council

■ Adults Surviving Child Abuse

■ Ministry of Health Mental Health Clinical Advisory

Council

■ Ministry of Health Mental Health Program Consumer

Sub-committee

■ NSW Police Force

■ NSW Rape Crisis Centre

Academics that reviewed and endorsed the guidelines

include:

■ Professor Moira Carmody, University of Western

Sydney’s Centre for Educational Research, former

member of the National Council to Reduce Violence

against Women and their Children, national expert on

sexual assault prevention education

■ Dr Lesley Laing, Senior Lecturer, Undergraduate and

Pre-service Programs, Program Co-director, Faculty of

Education and Social Work, University of Sydney,

former Director of the Education Centre Against

Violence (ECAV)


SECTION 2

Sexual Safety and Mental Health

SECTION 2

Sexual Safety and Mental Health

2.1 Defining sexual safety

Sexual safety refers to the respect and maintenance of an

individual’s physical (including sexual) and psychological

boundaries.

Core elements of sexual safety in a mental health service

include:

■ A safe physical environment

■ Recognition of the rights of consumers to physical

and psychological safety

■ Assessment of the consumer’s vulnerability or

potential to harm others

■ Identification of the consumer’s past experience of

sexual assault

■ Consideration of how the service environment could

be improved, including adoption of gender-sensitive

practices

■ Monitoring of professional boundaries

■ Management of sexually disinhibited behaviour and

prevention of sexual activity in an inappropriate

context or setting

■ Provision of professional development for staff

■ Appropriately responding to sexual assault and

harassment

■ Proper reporting and recording of sexual safety

incidents, and feeding back outcomes of cause

analysis into safety improvement processes at the

service level.

2.2 The importance of sexual safety for people with a mental illness

Mental health consumers are exposed to a number of

potential risks, particularly when they are acutely unwell.

Often these risks are related to their own behaviour or to

the behaviour of other consumers, or are a direct result

of their mental illness. Others relate to safety risks from

their care or treatment. This makes mental health

consumers a particularly vulnerable group within the

health sector.

Mental health consumers can be more vulnerable to

sexual assault in particular for a number of reasons,

such as:

■ Low self esteem and confidence

■ Social isolation and loneliness

■ Poor social and communication skills

■ Impaired judgement, due to their mental illness,

medication(s) prescribed for their illness or drug and

alcohol abuse, or a combination of these

■ Interruption of usual developmental stages due to

onset of mental illness combined with limited

education regarding relationships, appropriate sexual

behaviour and sexual safety.

In the community, this complex mix can also include an

increased likelihood of living in poverty with fewer

resources and options to change their living circumstance

and lack of access to outside assistance. In an inpatient or

residential rehabilitation setting, the power imbalance

between staff and consumers, either real or perceived,

can lead to a fear of retribution if the disclosure involves

a staff member.

According to research, the prevalence of people with a

mental illness who have been exposed to or have

experienced personal trauma, including sexual abuse and

violence, is high. There is also evidence to suggest that:

■ The influence of violence can persist long after the

abuse has stopped.

■ The more serious the abuse, the greater its impact on

physical and mental health.

■ The impact over time of different types and multiple

episodes of abuse appear to be cumulative (Evans

2007; Golding 1999; Taft 2003; WHO 2000).

■ Suicidal ideation is more common among victims/

survivors of sexual assault than the general population

(Stepakoff, 1998) and younger victims/survivors may

be at particular risk of actually attempting suicide

following rape (Petrak, 2002).


This highlights the need for greater awareness of the

sexual vulnerability of people with a mental illness, and

the link between mental health issues and prior sexual

assault and violence.

It also confirms the important responsibility mental health

services have to ensure that policies and procedures are in

place to support consumers to be sexually safe, and that

care and treatment plans take account of sexual safety

issues and adopt a trauma-informed care approach.

2.3 Sexual safety incident types

For the purposes of these guidelines, the types of

behaviour that can breach and/or compromise the sexual

safety of a mental health consumer have been split into

the following three incident types:

■ Sexual assault and harassment

■ Consensual sexual activity in an inappropriate context

or setting

■ Sexually disinhibited behaviour

Within the context of these guidelines, each of these

behaviours is referred to as a ‘sexual safety incident’.

2.3.1 Sexual assault and harassment

Definitions

Sexual assault is a broad term used to describe a range

of sexual acts committed against a person without their

consent. It occurs when:

■ a person is forced, coerced or tricked into sexual acts

against their will or without their consent, or

■ a child or young person under 16 years of age is

exposed to sexual activities, or

■ a young person between 16 and 18 years of age is

exposed to sexual activities by a person with whom

they have a relationship of ‘special care’ e.g.. step-

parent, guardian, foster parent, health practitioner,

employer, teacher, coach, priest, etc.

Sexual assault is a crime of violence with serious

consequences. Conviction for sexual assault is punishable

by law and depending on the category of assault, can

carry a gaol term. The Crimes Act 1900 sets out offences

of a sexual nature at Part 3, Division 10. See Appendix C

– Relevant standards and the legislative framework for

further information about what this Act says.

Sexual harassment can occur between any combinations

of individuals and is defined by the Australian Human

Rights Commission as ‘unwelcome conduct of a sexual

nature which makes a person feel offended, humiliated

and/or intimidated where that reaction is reasonable in

the circumstances.’

Sexual harassment can involve conduct such as:

■ unwelcome touching, hugging or kissing

■ staring or leering

■ suggestive or offensive comments or jokes

■ unwanted invitations to go out on dates or requests

for sex

■ intrusive questions about an individual’s private life

or body

■ unnecessary familiarity, such as deliberately brushing

up against someone

■ insults or taunts of a sexual nature

■ sexually explicit emails or SMS messages

■ behaviour which would also be an offence under the

criminal law, such as physical assault, indecent

exposure, sexual assault, stalking or obscene

communications.

Sexual harassment is not sexual interaction, flirtation,

attraction or friendship which is invited, mutual,

consensual or reciprocated.

Sexual assault and sexual harassment potentially affect all

members of the community. However, there are certain

groups that are more likely to be targeted than others,

and this includes men and women with a mental

impairment (Cook, 2001).

Beyond Belief, Beyond Justice (Goodfellow and Camilleri,

2003) notes that women with cognitive impairment

(including women with cognitive impairment from mental

illness) are especially vulnerable to abuse, particularly

those who are homeless or living in boarding houses or

institutional settings.

Impact

Sexual assault and sexual harassment for those who

experience it can affect their short and long-term physical

and mental health, their economic wellbeing, and their

feelings of safety.

Of all the traumatic stressors researched, trauma of sexual

assault is the strongest predictor of Post Traumatic Stress


Disorder and is associated with increased rates of other

mental disorders including depression, anxiety, anti-social

personality disorder, substance dependence, suicidal

ideation and suicide attempts.

The immediate emotional consequences of sexual assault

might include terror, anguish, disgust, personal vulnerability,

shock, numbness and denial. The long-term emotional

impact can be experienced in many ways including:

■ Disturbed sleep

■ Frequent nightmares

■ Flashbacks to the assault

■ Embarrassment, shame, eroded self-esteem

■ Poor body image, weight gain used as a protective

mechanism

■ Depression and anxiety

■ Hostility, anger, and behavioural problems

■ Self-harming and compulsive behaviours (including

self-mutilation, reckless behaviour, drug and/or

alcohol abuse)

■ Relationship difficulties and loss of sexual confidence

■ Feelings of isolation, guilt or self-blame, suicidal

thoughts and suicide attempts

Overall, the reactions to sexual assault of both women

and men tend to be similar (Crome, 2006), but research

addressing the impact on men has been limited.

Some impacts of particular relevance to males include

sexual orientation conflict, homophobia, male specific

sexual dysfunction and compulsions, and masculine

identity confusion.

Sexual harassment is a type of sexual assault, and victims/

survivors of severe or chronic sexual harassment can

suffer the same psychological effects as victims/survivors

of sexual assault.

2.3.2 Consensual sexual activity in an inappropriate context or setting

Definitions

For the purposes of the guidelines, consensual sexual

activity is any activity of a sexual nature (sexual touching,

sexual intercourse, oral sex) that occurs between people

over the age of 16 years after mutual sexual consent has

been provided by those involved, who have been

assessed as having the capacity to consent.1 The term

inappropriate context or setting refers to consensual

sexual activity taking place in an environment or

associated with a set of circumstances that is not

considered to be suitable, such as:

■ An acute inpatient setting

■ A public area of a non acute, residential or

rehabilitation unit

■ When a health worker suspects that a consumer has

been coerced into engaging in sexual activity or was

unwell at the time that the activity occurred.

Impact

The impact for consumers of consensual sexual activity in

an inappropriate context or setting will vary based on the

individual circumstances involved, but could involve:

■ sexual exploitation

■ damage to self esteem and other relationships

■ sexually transmitted infections or pregnancy

Witnessing sexual activity, even if it is consensual, can

also be traumatic for others within the service setting,

particularly those that have previously experienced sexual

assault or harassment.

When a mental health worker or clinician is involved, the

consequences could include:

■ significant and enduring harm to the consumer

■ damage to the trust that should exist between

consumer and mental health worker or clinician

■ the mental health worker or clinicians decisions about

care and treatment may be influenced to the

consumer’s detriment

■ a breach of the NSW Health Code of Conduct

(PD2012_018) resulting in disciplinary action against

the mental health worker or clinician

■ criminal charges being laid against the mental health

worker or clinician.

1 Note: It is a crime to have sexual intercourse with a young person between the ages of 16 and 18 if you are in a relationship of ‘special care’ with that young person, regardless of whether they consent to this. ‘Special care’ relationships include step-parent, guardian, foster parent, health practitioner, employer, teacher, coach, priest, etc.


2.3.3 Sexually disinhibited behaviour

Definitions

Sexual disinhibition is an inability to restrain sexual

impulses and involves behaviour or talk which is

considered inappropriate for a particular environment.

This behaviour arises for a variety of reasons that can

include a mental illness or disorder, dementia or

Alzheimers, or the side effects of medication.

Behaviours can exist on a continuum and can escalate in

severity, from an increase in sexual thoughts through to

indiscriminate sexual activity.

Impact

Sexually disinhibited behaviour can be embarrassing,

distressing and potentially dangerous for the person

exhibiting the behaviour as well as for those that may be

exposed to it. It can also negatively impact on existing

relationships and for those that have experienced a prior

incident of sexual assault or harassment, being exposed to

this behaviour can trigger strong feelings of fear and anxiety.

Sexually disinhibited behaviour also has the potential to

make consumers exhibiting this behaviour vulnerable to

sexual assault or harassment.

2.4 Rights and responsibilities regarding sexual safety

In protecting the sexual safety of consumers, mental

health services must ensure that the consumers’ rights

are respected. Services will also need to understand and

promote the responsibilities all members of the service

have while in the care of or involved with the service.

2.4.1 Mental health consumers in all settings have the right to:

■ Receive clear information and advice that takes

account of their cultural background, gender, sexual

orientation, age and personal experiences regarding:

– their rights and responsibilities in relation to sexual

safety;

– the standards of appropriate behaviour that exist in

the service setting;

– the process for addressing a sexual safety incident;

– the support services available should they

experience sexual assault or harassment; and

– how to manage sexual health issues, such as

contraception, sexually transmitted diseases (STDs)

and pregnancy.

■ Be heard and believed regarding their experience

of sexual assault and harassment.

■ Be treated with compassion and understanding

when they disclose incidents that have compromised

their sexual safety.

■ Be supported by the person of their choice after a

sexual safety incident has occurred, whether this is a

family member, friend, preferred staff member or

other advocate.

■ Receive prompt treatment once their experience of

sexual assault and harassment is disclosed, whether

this experience occurred prior to or after their

admission to a mental health service.

■ Be informed about their options after experiencing

a sexual assault or sexual harassment, and have their

wishes respected, particularly regarding whether to:

– Remain within the service environment in which the

assault occurred, or be moved to another environment;

– Disclose their experience of sexual assault,

including to their carer and/or family;

– Make a formal complaint to the NSW Police Force,2

Talk to a Sexual Assault Service; and

– Undergo a medical or forensic examination.

■ Be protected from further contact with the alleged

perpetrator of a sexual assault or sexual harassment

when in the care environment, regardless of whether

this is a staff member, a consumer, the consumer’s

family member, carer or friend or a casual visitor.

2 An allegation of sexual assault must be reported to NSW Police Force if it involves an employee of NSW Health – PD2006_026

SEXUALLY DISINHIBITED BEHAVIOUR

Increase in sexual

thoughts

Engaging in indiscriminate sexual activity

Being hypersexual

eg masturbating in public

Sexualised demeanour and general disinhibition

Being overly familiar or

touching others

Wearing overly revealing

clothing

Removing clothes when not required


■ Receive support to access sexuality and sexual

health education, if they wish to be involved in such

education, and contribute to determining the topics

that such education will cover.

2.4.2 All members of a mental health service have the right to:

■ Feel safe from acts that compromise or breach their

sexual safety while in a mental health service environment.

■ Be consulted about and provide input to the

sexual safety standards developed to govern

appropriate behaviour within the service they are

involved with.

2.4.3 Mental health services in all settings have a responsibility to:

■ Implement and monitor compliance with these

Guidelines to establish and maintain the sexual

safety of the consumers who use their service.

■ Develop sexual safety standards that define

appropriate behaviour for the service setting in

consultation with all members of the service,

including consumers and their families and carers –

see Appendix A for example standards.

■ Provide clear information and advice to

consumers that takes account of their cultural

background, gender, sexual orientation, and personal

experiences regarding:

– their rights and responsibilities in relation to sexual

safety;

– the sexual safety standards that exist in the service

setting;

– the process for addressing a sexual safety incident;

– the support services available should they

experience sexual assault or harassment; and

– how to manage sexual health issues, such as

contraception, sexually transmitted diseases (STDs)

and pregnancy.

■ Ensure consumers are supported to access

condoms in service settings where sexual activity is

recognised as appropriate e.g. non-acute inpatient/

rehabilitation and community.

■ Be non-judgemental, compassionate and

understanding when a consumer discloses their

experience of sexual assault or harassment.

■ Organise prompt treatment for a consumer once

their experience of sexual assault and harassment is

disclosed, whether this experience occurred prior to

or after their admission to a mental health service.

■ Explain the available options the consumer should

consider if they have experienced sexual assault or

harassment, and ensure the consumer’s wishes

are respected unless legislatively prohibited.

■ Protect the consumer from further contact with

the accused perpetrator, regardless of whether this

is a staff member, another consumer, the consumer’s

family member, carer or friend or a casual visitor.

■ Support the consumer to be free from pressure

to engage in sexual activity with another person,

including the consumer’s partner or spouse.

■ Help the consumer to access sexuality and

sexual health education that is appropriate to

their cultural background, gender, sexual

orientation, age and personal experiences, and

ensure that consumers are able to contribute to

determining the topics such education should involve.

2.4.4 All members of a mental health service have a responsibility to:

■ Respect the rights of others to feel safe from acts

that compromise or breach their sexual safety,

regardless of their cultural background, gender and

sexual orientation.

■ Read the information provided to them about

sexual safety within the service environ and ask

questions as required to support their understanding.

■ Adhere to the sexual safety standards that

define appropriate behaviour for the service

setting.

2.5 Relevant legislation, standards/rights and policies

2.5.1 Legislation■ Anti Discrimination Act 1977

■ Child Protection (Offenders Registration) Amendment

Act 2000

■ Children and Young Person’s (Care and Protection)

Act 1998

■ Crimes (Sentencing Procedure) Act 1999

■ Crimes Act 1900

■ Criminal Procedure Act 1986

■ Evidence Act 1995

■ Health Administration Act 1982

■ Health Records and Information Privacy Act 2002

■ Victims Rights Act 1996

■ Ombudsman Act 1974

■ Commission for Children and Young People Act 1998


■ Child Protection (Working with Children) Act 2012 –

not yet in force.

■ Health Services Act 1997

Links to some of these documents online, along with

extracts that pertain specifically to these guidelines, are

provided at Appendix B and C.

2.5.2 Standards and rights■ Charter of Victims Rights (Extract from the Victims

Rights Act 1996 – Part 2, Section 6)

■ National Statement of Rights and Responsibilities of

Consumers of Mental Health Services

■ NSW Ministry of Health Charter for Mental Health

Care in NSW

■ NSW Police Force, Health and Office of the Director

of Public Prosecutions: Guidelines for Responding to

Adult Victims of Sexual Assault 2006

■ UN Declaration – Rights of Disabled Persons

■ UN Principles for the Protection of Persons with

Mental Illness and for the Improvement of Mental

Health Care

2.5.3 Associated NSW Health policies■ Child Protection and Wellbeing – Information

Exchange PD2011_057

■ Child Protection Issues for Mental Health Services –

Risk of Harm Assessment Checklist PD2006_003

■ Child Protection Roles and Responsibilities –

Interagency PD2006_104

■ Child related allegations, charges and convictions

against employees PD2006_025

■ Complaint Management Guidelines GL2006_023

■ Complaint or Concern about a Clinician –

Management Guidelines GL2006_002

■ Complaint or Concern about a Clinician – Principles

for Action PD2006_007

■ Complaints Management Policy PD2006_073

■ Coroners’ Cases and Amendments to Coroners Act

1980 PD2005_352

■ Criminal allegations, charges and convictions against

employees PD2006_02

■ Disciplinary Process in NSW Health – A Framework for

Managing the Disciplinary Process in NSW Health

PD2005_225

■ Domestic Violence – Identifying and Responding

PD2006_084

■ Employment Screening PD2008_029

■ Improper Conduct – Procedures for Recruitment/

Employment of Staff and Other Persons PD2005_109

■ Incident Management Policy PD2006_030

■ Interpreters – Standard Procedures for Working with

Health Care Interpreters PD2006_053

■ Keep Them Safe – Making a Child Protection Report

IB 2010_005

■ Legal Matters of Significance to Government

PD2006_009

■ Lookback Policy PD2007_075

■ NSW Health Code of Conduct PD2012_018

■ NSW Health Frontline Policies and Procedures for

Child Protection and Wellbeing (update being finalised

at time of printing)

■ NSW Health Subpoenas PD2010_065Open Disclosure

PD2007_037

■ Privacy Manual (Version 2) – NSW Health

PD2005_593

■ Protecting Children and Young People PD2005_299

■ Reportable Incident definition under section 20L of

the Health Administration Act PD2005_634

■ Reportable Misconduct under the Medical Practice

Act – Guidelines for practitioners, August 2008

IB2008_062

■ Sexual Assault Services Policy and Procedure Manual

(Adult) PD2005_607

■ Statutory Guidelines under the Health Records and

Information Privacy Act 2002

■ Violence Prevention & Management Training

Framework for the NSW Public Health System

PD2012_008

Sexual Safety of Mental Health Consumers Guidelines NSW HealtH PaGe 15Sexual Safety of Mental Health Consumers Guidelines NSW HealtH PaGe 15

KEY POINTS – SEXUAL SAFETY AND MENTAL HEALTH

■ Sexual safety refers to the respect and maintenance

of an individual’s physical (including sexual) and

psychological boundaries.

■ Mental health consumers are exposed to a number of

potential risks, especially when they are acutely

unwell, and are more vulnerable to sexual assault in

particular.

■ The prevalence of people with a mental illness who

have been exposed to or have experienced personal

trauma, including sexual abuse and violence, is high.

■ The types of behaviour that can breach and/or

compromise the sexual safety of a mental health

consumer are:

– Sexual assault and harassment

– Consensual sexual activity in an inappropriate

context or setting

– Sexually disinhibited behaviour

■ Sexual assault is when:

– a person is forced, coerced or tricked into sexual

acts against their will or without their consent;

– a child or young person under 16 years of age is

exposed to sexual activities, or

– a young person over the age of 16 but under the

age of 18 years of age is exposed to sexual

activities by someone with whom they have a

‘special care’ relationship e.g. step-parent,

guardian, foster parent, health practitioner,

employer, teacher, coach, priest, etc.

■ Sexual assault is a crime.

■ Sexual harassment is unwelcome conduct of a sexual

nature which makes a person feel offended,

humiliated and/or intimidated where that reaction is

reasonable in the circumstances.

■ Consensual sexual activity is any activity of a sexual

nature that occurs:

– between people over the age of 16 years, or over

the age of 18 years if there is a ‘special care’

relationship between those involved; and

– after mutual sexual consent has been provided by

those involved; and

– when those involved have been assessed as having

the capacity to consent .

■ Sexually disinhibited behaviour involves actions or talk

of a sexual nature that is considered inappropriate for

a particular environment.

■ In protecting the sexual safety of consumers, mental

health services must ensure that the consumer’s rights

are respected and the responsibilities of all members

of the service are promoted and upheld. See Section

2.4 for further information.

■ Services will need to familiarise themselves with the

range of relevant legislation, standards and NSW

Health policies. See Section 2.5 for further

information.

NSW HealtH Sexual Safety of Mental Health Consumers GuidelinesSexual Safety of Mental Health Consumers Guidelines NSW HealtH PaGe 16

Fostering a culture that supports sexual safety

SECTION 3

For consumers to feel sexually safe, services will need to

foster a culture that encourages and supports consumers

to report a sexual safety incident. This will involve strong

leadership that inspires transparency and trust.

Transparency means the degree to which information

flows freely within the service, among managers and

staff, and outward to consumers, their families and

carers, and other key stakeholders. Trust means members

of the service can communicate upward and honestly,

teams can challenge their own assumptions freely, and

managers and clinicians can successfully communicate

important messages to staff.

Training and education, promotion and collaboration will

all play a critical role in supporting services in this regard.

3.1 Training and education

3.1.1 Supporting mental health staff

Service staff

Training is essential for all frontline staff and managers

around sexual safety and sexual assault and harassment.

Awareness and knowledge of the impact of sexual

assault and harassment, and the implications of sexual

offender tactics, informs clinical practice and can

significantly improve treatment outcomes for consumers.

This in turn can reduce the possibility of consumers being

re-traumatised, both while in the care of a mental health

service and when they move into the community.

Training also provides staff with the opportunity to reflect

on many of the common myths held within society about

sexual assault. This reflection in conjunction with

evidence-based facts can have a positive impact on

attitudes around sexual assault and drive cultural change

where required.

KEY ACTIONS/POINTS FOR ALL SETTINGS

■ All staff need to be aware of and cognisant with their

Local Health District policy and procedures that

outline their responsibilities in relation to preventing

potential sexual assault and harassment and

responding appropriately if an assault or harassment

occurs.

■ Staff in all settings should be provided with optimal

opportunity to attend training on managing sexual

safety and this should be provided within an

orientation period where possible.

■ Such training must include advice about how to

appropriately take a consumer’s sexual assault history.

Other areas or topics for training include:

– The increased vulnerability of people with a mental

illness to sexual assault and harassment

– Management of sexuality in different health care

settings

– Recognition of signs of sexual assault in different

consumer groups

– What behaviour constitutes sexual harassment

– Management of disinhibitive behaviour

– Processes for reporting a sexual assault to Police

and requirements for preserving a potential crime

scene

– An understanding of different religious and cultural

mores

– Management and support of the consumer who

has experienced previous sexual assault or

harassment

– The sexual rights of people with a mental illness

– Child protection issues in relation to children and

young people living with or related to a consumer

■ Education may also be required around how to

discuss sexual safety issues with consumers and

their families and carers in a sensitive and non-

sexualised way.

■ Any training and education should include gender-

sensitive and trauma informed care practice principles.

Having clinical supervision systems in place will also

support staff in developing their understanding of

gender sensitive practice, trauma informed care, and

professional boundaries.

■ Refresher training should be considered for all staff

annually.


KEY ACTIONS/POINTS FOR ACUTE INPATIENT

■ Training for staff working in an acute inpatient setting

must include risk assessment of consumers for

victimisation or offending and management of

disinhibitive behaviours.

■ Support to appropriately utilise tools such as

environmental audits will also be required.

KEY ACTIONS/POINTS FOR NON-ACUTE/

RESIDENTIAL AND COMMUNITY

■ Promoting safety within settings where a consumer’s

right to consensual sexual activity is respected can be

supported through education on topics such as

assessing a consumer’s capacity to provide sexual

consent and understanding the tactics of coercion.

■ Staff in community based and residential services who

are involved in case management will also need

information and advice regarding how to manage the

particular issues that exist when home visiting.

Consumer workers and representatives

Consumers often feel a particular level of trust in confiding

in and disclosing to consumer workers. This makes consumer

workers vital members of the service environment.


■ Consumer workers must be provided with education

and training that mirrors the training provided to

service staff.

■ This will support them to play a pivotal role in

providing advocacy in the event of sexual harassment

or assault within services and to gain information

from a trauma focused perspective.

■ Consumer workers and representatives also need to

be able to access training in terms of reflective

practice around appropriate boundaries and ethical

practice within the context of their workplace roles.

Clinicians already receive this training as part of their

health qualifications.

Volunteers

Anyone who carries out volunteer work within a mental

health service does so to enhance services for consumers.

Accordingly, they should be provided with adequate

support to help them to be aware of and understand

sexual safety issues for consumers.


Volunteers will need education and training regarding:

■ The rights and responsibilities of the consumers who

use the service;

■ Their own responsibilities and the NSW Health Code of

Conduct that applies to all health positions or roles;

■ How to respond if they receive a disclosure of sexual

assault, suspect someone has been sexually assaulted

or witness a sexual assault; and

■ How to respond if they become aware in the course

of their duties that a child or young person may be at

risk of significant harm.

3.1.2 Empowering consumers Empowerment in the context of a mental health service is

the meaningful participation of people with mental illness

in decision making and activities that give them increased

power, control, or influence over important areas of their

lives. Any process that prepares people to participate

more effectively in an activity that increases their power,

control, or influence can be considered empowering.

Consumers can participate more effectively in the

establishment and maintenance of their sexual safety

through the provision of information and opportunities

to be involved in education programs.

It is also important that consumers understand the link

between sexual safety and sexual health. The World

Health Organisation (WHO) defines sexual health

as follows.

Sexual health

A state of physical, emotional, mental and social well-being related to sexuality, including the absence of disease, dysfunction or infirmity; a positive and respectful approach to sexuality and sexual relationships; the possibility of having pleasurable and safe sexual experiences, free from coercion, discrimination and violence, and; respect for the sexual rights of all persons.

World Health Organisation


Good sexual health can facilitate the development of

respectful, healthy and equitable relationships and

improve attitudes toward gender equity, gender roles,

and violence, particularly violence against women.


■ Information for consumers should include advice

about their rights and responsibilities as they pertain

to the service they are involved with as well as the

sexual safety standards of the service. Staff can provide

this information to consumers in a written format on

admission and assist them with understanding the

implications at daily unit meetings, within case

management relationships and within the context

of daily care.

■ Consumers should also be advised of the complaints

process, including how to access the Official Visitors.

■ Information and resources need to be made available

in community languages as well as English and access

to interpreters and Aboriginal liaison staff made

available.

■ Consumers in all settings should be provided with

opportunities to participate in sexuality education

programs as part of a wider preventative approach.

■ Such sexuality education must include more than just

the biological details of reproductive sex and sexual

health, but also engagement with the meaning and

negotiation of sexual consent (Carmody, 2003, 2005;

Carmody and Willis, 2006; Powell, 2007).


■ While consumers in an inpatient setting are not

encouraged or supported to engage in sexual activity,

education and training around ethical behaviour and

developing respectful relationships can be beneficial.

Such education could include information about:

– Building self-esteem and resilience

– Developing the social skills to cultivate and

maintain relationships

– Different types of relationships

– Coping with relationship difficulties or rejection

■ Helping consumers to develop respectful relationships,

and promoting alternative ways of relating that are

non-violent and non-sexual, can provide an important

contribution to the establishment and maintenance of

a sexually safe environment. This can also help to

prepare consumers to enjoy a healthy and safe sex life

once they are well enough to leave the inpatient setting.

■ Communicating with consumers verbally about how

some of their behaviour can impact on consumers

who may have experienced past trauma can also be

an effective education strategy.



■ In non-acute/residential and community settings, a

significant proportion of consumers are sexually active

and may participate in high-risk behaviours, placing

them at an increased risk of sexually transmitted

infections (STIs), including gonorrhoea, chlamydia,

syphilis and HIV, as well as unwanted pregnancy.

■ Mental health staff in these settings have an important

role to play in providing educative information that

promotes sexual health as part of routine care.

■ Sexuality education and training should also be

offered to consumers in a non-acute/residential

setting. In a community setting, information about

how to access this education can be provided. Such

education can help consumers to recognise and

identify inappropriate sexual behaviours, their own

and others, develop strong self-protective knowledge

and skills3 (e.g. how to assert their right to say ‘no’) as

well as develop a positive and respectful approach to

their sexuality and to sexual relationships.

■ This education and training could include information

about:

– Sex and relationships, including marriage, same sex

attraction and parenting

– The physical mechanics of sex, including

reproduction and masturbation

– Appropriate and inappropriate expressions of

sexuality

– Sexually transmissible infections

– Safer sex and contraception

– Sexuality in older age

3.1.3 Recognising families, friends and carers

A consumer’s family and/or carer are an integral part of

the care team. Accordingly, they will require information

to enable them to understand the importance of sexual

safety for the consumer they support and how they can

help to ensure it is maintained.

3 Beyond Belief, Beyond Justice – Disability Discrimination Legal Service Inc, Victoria – November 2003



■ Families and carers should be provided with advice

about the consumer’s rights within the service setting

and pathways for complaint if these rights are

not upheld.

■ Additionally, they will need information that indicates

what will happen if the consumer they support is

sexually assaulted or harassed, or sexually assaults or

harasses someone else, and the referral services that

are available to help with understanding issues

around sexual assault. This information could include

advice about disinhibited behaviour, where relevant,

to ensure the consumer’s partner or family is aware

of the connection between this type of conduct and

the consumer’s illness, and to help them to help the

consumer manage their behaviour when in a

manic phase.

■ Families and carers will also require information

regarding the consumer’s responsibilities while

involved with the service and the sexual safety

standards that define appropriate behaviour for the

consumers involved with the service.

3.2 Promoting sexual safety

Promoting sexual safety is an important component of

any strategy to prevent sexual assault and harassment.

The most effective way to promote sexual safety is through

the adoption of an ethos that promotes, encourages and

models mutual respect in its relationships between staff,

between staff and consumers, and between consumers.

Information regarding sexual assault, and about support

services for people who have been assaulted in particular,

should also be readily accessible. The World Health

Organisation recommends that health services consider:

■ Compiling a list of local services and telephone

numbers that can be kept in a place that is easily

accessible.

■ Displaying posters about sexual assault and where to

go for help on the walls of the facility (having

information prominently displayed may make people

who have been assaulted feel more comfortable in

disclosing and talking about the sexual violence in

their lives). See Appendix D, E and F for examples of

information and posters that could be utilised for this

purpose.

■ Placing pamphlets and brochures regarding sexual

assault in designated areas, such as toilets and

gender-specific areas, so that consumers can take them

away with them or read the information in private.

Other practical promotion strategies include:

■ Developing sexual safety standards of appropriate

behaviour in consultation with consumers and their

carers and families.

■ Regularly communicating and promoting these

standards to all members of the service, including

casual visitors, such as tradespeople or couriers, via

posters or written materials.

■ Conducting periodic surveys or forums involving

consumers, carers and families on the quality of the

service, including matters relating to sexual safety.

■ Prominently displaying the service’s position on sexual

safety in the adult acute inpatient unit.

■ Discussing behavioural expectations and sexual safety

in consumer unit meetings and programs.

■ Providing gender specific programs, groups and

activities.

■ Changing practices to consider sexual safety issues,

and communicating these changes to all staff.

■ Conducting a clinical review of every sexual safety

incident as a matter of urgency.

■ Reporting every sexual safety incident through the

mental health service incident reporting system. (See

Reporting and Recording for further information.)

3.3 The importance of collaboration

Maintaining a sexually safe environment within the

service, supporting consumers receiving treatment within

the community to maintain their own sexual safety, and

responding appropriately when a sexual safety incident

occurs, will require collaboration with a range of key

stakeholders.

3.3.1 ConsumersConsumers have a critical role to play in contributing to

the sexual safety of the service environment, and to their

own sexual safety, and the safety of others, if they are

receiving treatment within the community. Accordingly,

they need to be actively involved in developing sexual

safety standards of appropriate behaviour for the service

they are involved with.

Working collaboratively with consumers in relation to

managing sexual safety can also help to empower them,

which is an important component of the recovery process

in relation to their mental illness.


3.3.2 Families and carersA consumer’s family and/or carer are an integral part of

the care team. They can offer critical emotional support

to a consumer who has experienced sexual harassment,

assault or violence, as well as support to liaise with health

care and other professionals, such as Sexual Assault

Services and Police. They can also help the consumer to

understand and adhere to the sexual safety standards of

the service.

However, staff must ensure that the consumer’s carer,

family or friends are only advised of any sexual safety

incident with the express consent of the consumer.

Additionally, staff should be mindful of the high

prevalence of intra-familial sexual assault for consumers.

Family members may have been or may continue to be

perpetrators of abuse, and this must be considered when

organising family visits or conferencing.

Staff should also familiarise themselves with the NSW

Health Frontline Procedures for the Protection and

Wellbeing of Children and Young People (revised

procedures being finalised at the time of printing) and

assess the safety risk to children and young people under

18 who may be living with or have access to an adult

consumer exhibiting behaviours that may place a child or

young person at risk of harm.

3.3.3 General practitioners (GPs)GPs are uniquely placed to provide information and

support to consumers, as well as their family and carers,

in relation to sexual safety and sexual health matters and

can provide long-term continuity of care that will support

consumers to build a trusting relationship with them.

For those consumers being treated within the community

or in a residential setting, the role of the GP in relation to

sexual safety can include:

■ Providing information about treatment options

regarding sexual assault or harassment

■ Referring the consumer to local support services, such

as a counsellor or the local Sexual Assault Service or

rape crisis centre

■ Discussing contraception, STIs and other sexual health

issues

■ Organising a forensic examination if an assault has

occurred recently, or conducting this exam if they

have been trained in this field and have the necessary

equipment

■ Providing follow-up care

All consumers being treated outside of a hospital setting

should have a regular GP.

Developing shared care arrangements with a consumer’s

GP, or linking consumers with a GP in the area, should be

a priority for mental health services and all services should

have a strategy in place, at either a local or Local Health

District level, to strengthen relationships with local GPs.

3.3.4 NSW Health Sexual Assault Services

NSW Health Sexual Assault Services are based in hospitals

or community health centres across NSW. They are

staffed by specially trained counsellors and are accessible

24 hours a day. Their role is to provide specialist guidance

to health staff in responding to incidents as well as

counselling and relevant medical assessment and

treatment for people who have experienced sexual

assault and their family/significant others. This includes:

■ crisis and ongoing counselling

■ specialist medical and forensic services

■ court preparation and support

■ community education and prevention

■ professional training and consultation

■ advocacy

Differing perspectives, along with language differences

across service models and frameworks, can be barriers to

developing good collaborative relationships between

mental health and Sexual Assault Services. However,

collaboration between these services offers invaluable

support for staff, as well as better outcomes for the

consumer who has experienced the assault, through:

■ access to other knowledge and information

■ consultancy on issues of sexual assault and mental

health

■ supportive debriefing where appropriate

■ breaking down staff isolation

■ introduction of new ideas and strategies from people

who are outside the sector

■ support and advocacy for services in addressing the

needs of consumers


Mental health services should look to develop a close

partnership with their local Sexual Assault Service, with

consideration given to inviting key members of the Sexual

Assault Service to visit the service on a regular basis so

that consumers are familiar with them. The Sexual Assault

Service may also be able to provide recurrent education

sessions with consumers around relevant topics, or visit to

talk about what they do and how they can help

consumers when required. See the NSW Health Sexual

Assault Webpage (http://www.health.nsw.gov.au/

publichealth/sexualassault/index.asp ) for further

information.

3.3.5 NSW Police ForceThe role of the NSW Police Force is to:

■ ensure that the Charter of Victims’ Rights is observed

at all times

■ provide protection to victims/survivors of sexual

assault who are at immediate or continuing risk, using

relevant powers

■ investigate reports of sexual assault

■ assess the case and decide if there is adequate

evidence to proceed with an investigation or to

charge an assailant

■ apprehend and charge an alleged perpetrator with

sexual assault.

Every Local Area Command in NSW has a designated

Mental Health Contact Officer (MHCO) at Inspector Rank.

One of the responsibilities of the MHCO is interagency

liaison with local NSW Mental Health Services. Mental

health services can obtain their local MHCOs contact

details via their Emergency Mental Health Local Protocol

Committee member or by making a request through their

Local Area Command. The MHCO can be engaged for

any interagency issue or for facilitating training for staff

involving Police.

Many NSW Police Officers have also received Mental

Health Intervention Team (MHIT) training and some Police

Officers have specific training in taking sexual assault

statements in a sensitive and respectful way from people

who have been assaulted. Mental health services can ask

at their Local Area Command for the support of a MHIT

trained Officer, and can request a female Police Officer, if

one is available.

Mental health services should ensure that they establish

and maintain a good working relationship with the local

Police service, which should include the development of

local protocols to manage reporting of sexual assault or

harassment.

3.3.6 Other agenciesThere are a range of other agencies that can support

both staff and consumers when there is an allegation of

sexual assault or harassment. These include what is in the

table below.

Services should familiarise themselves with these agencies

and the type of support they offer so that they are able

to provide relevant options to consumers as required

should they experience a sexual safety incident. A handout

for consumers may be useful that provides the contact

information for these and other local agencies and

support groups.

Adults Surviving Child Abuse (ASCA) www.asca.org.au

Child and Adolescent Sexual Assault Counsellors Inc www.casac.org.au

The Gender Centre www.gendercentre.org.au

Intellectual Disability Rights Service www.idrs.org.au

NSW Department of Community Services www.community.nsw.gov.au

NSW Rape Crisis Centre www.nswrapecrisis.com.au

NSW Service for the Treatment and Rehabilitation of Torture and Trauma Survivors(STARTTS):

www.startts.org.au

Transcultural Mental Health Centre www.dhi.health.nsw.gov.au/tmhc

Women’s Legal Services NSW www.womenslegalnsw.asn.au

http://www.health.nsw.gov.au/publichealth/sexualassault/index.asp

http://www.health.nsw.gov.au/publichealth/sexualassault/index.asp

http://www.asca.org.au/displaycommon.cfm?an=2

http://www.casac.org.au/contact.htm

http://www.gendercentre.org.au

http://www.idrs.org.au/_contact/www.idrs.org.au

http://www.community.nsw.gov.au/about_us/contact_us.html

http://www.nswrapecrisis.com.au/

http://www.startts.org.au/Default.aspx

http://www.dhi.gov.au/tmhc/default.aspx

http://www.womenslegalnsw.asn.au/contact-us.html


3.3.7 Partner programs/Community managed organisations (CMOs)

Mental health CMOs provide a range of interventions for

mental health consumers, including:

■ Promotion and prevention to early intervention

■ Family and peer support

■ Mentoring and counselling

■ Community awareness activities and

■ Education and training.

In many cases, a CMO can be a consumer’s primary

non-clinical service provider. This makes CMOs important

stakeholders whose capacity to support and encourage

consumers to consider their sexual safety and sexual

health should not be undervalued. CMOs can also

provide advice to mental health services in terms of

appropriate approaches to effectively engage consumers.

Working collaboratively with CMOs at local level can help

to ensure a complementary approach is taken to raising

awareness about sexual safety issues for consumers, which

avoids duplications, provides continuity of care and more

efficient use of limited resources.


KEY POINTS – FOSTERING A CULTURE THAT SUPPORTS SEXUAL SAFETY

Training and education

■ Training and education, promotion and collaboration

will all play a critical role in supporting services to

foster a culture that encourages and supports

consumers to report a sexual safety incident.

■ Training is essential for all frontline staff and managers

around managing sexual safety, inclusive of taking a

consumer’s sexual assault history. Such training must

include gender sensitive and trauma informed care

principles. Consumer workers and volunteers will also

need training. See Section 3.1 for further information.

■ Education should also be offered to mental health

consumers on topics relevant to the setting in which

they are receiving care e.g. building the social skills to

develop and maintain relationships for consumers in

an acute setting; sexuality and sexual health

education, including cultivating and maintaining

ethical relationships, for consumers in a non-acute/

residential setting.

■ For consumers in a community setting, help to access

such education should be offered if relevant.

Promotion

■ The most effective way to promote sexual safety is

through the adoption of an ethos that promotes,

encourages and models mutual respect in its

relationships between staff and consumers, between

staff, and between consumers.

■ Information regarding sexual assault, and about

support services for people who have been assaulted

in particular, should be readily accessible. See Section

3.2 for further information.

Collaboration

■ Maintaining a sexually safe environment within the

service, supporting consumers receiving treatment

within the community to maintain their own sexual

safety, and responding appropriately when a sexual

safety incident occurs, will require collaboration with

a range of key stakeholders, including:

– Consumers

– Families and carers

– GPs

– NSW Health Sexual Assault Services

– NSW Police Force

– Other agencies

– Partner programs/community managed or

non-government organisations

■ See Section 3.3 for further information.



SECTION 4

Preventing a Sexual Safety Incident

4.1 Sexual assault and harassment

4.1.1 Assessing vulnerability All consumers are vulnerable by the nature of their illness

and/or the experience of being hospitalised. Being female

in particular increases the consumer’s vulnerability to

being sexually assaulted or harassed, as is being under

the age of 18 years. Other factors that increase the risk

for a consumer of being sexually assaulted include:

■ Having a past history of being sexually assaulted

■ Being a young female experiencing their first admission

■ Being heavily medicated

■ Being intoxicated and/or having a comorbid drug and

alcohol condition

■ Having an intellectual disability

■ Being Aboriginal or Torres Strait Islander

■ Being a refugee/torture and trauma survivor

■ Experiencing a psychosis

■ Being a victim/survivor of domestic violence

■ Sexual disinhibition

■ Having a cognitive impairment e.g. delirium

■ Impaired communication skills e.g. English

competence, hearing speech or visual impairment


■ Assessing the vulnerability of a consumer to being

sexually assaulted and harassed can support staff to

better manage any risk to their sexual safety and

should be undertaken on the consumer’s admission.

■ Any existing screening process (e.g. for domestic

violence and/or elder abuse) should be broadened to

take account of any history the consumer may have

of experiencing or perpetrating sexual assault and

harassment (see below).

■ If a consumer is assessed as being vulnerable to sexual

assault, this assessment must be:

– Documented within the admission clinical

documentation, progress notes and management/

care plans, along with what steps will be taken to

address this vulnerability; and

– Communicated to all staff.

4.1.2 Taking an appropriate sexual assault and harassment history

Knowledge about a consumer’s previous history of being

subjected to sexual assault or harassment can inform staff

of the consumer’s particular needs and what may or may

not be problematic or ‘triggering’ situations for them.

Feeling safe within services is essential for healing and for

decreasing vulnerability to further victimisation.

Research indicates that people who have experienced

sexual abuse that occurs within an institutional

environment are unlikely to disclose the abuse unless they

are asked directly.

This reluctance is due to a range of factors, including:

■ denial

■ fear of stigmatisation

■ inability to trust

■ loyalty to the perpetrator

■ feelings of shame

■ inability to identify the experience as abuse or realise

that they have a right to safety

■ fear of retaliation by the perpetrator or others

■ fear of being labelled as a liar, attention-seeking or

out of touch with reality

Accordingly, taking a consumer’s sexual assault history

when they are admitted to a mental health service is

critical to enable staff to adequately support the consumer,

both in terms of their illness and their sexual safety while

involved with the service.

It is important, however, to ensure that this process is

carried out when the consumer is comfortable to do so.

For acute admissions, taking such a history should be

delayed until the consumer is stable.

Taking a consumer’s history of perpetrating sexual assault

is also vitally important to assess the risk that they may

continue to offend while involved with the mental health

service, separate them from consumers that have been

identified as vulnerable and to ensure they receive


appropriate support to recognise their behaviour as

inappropriate.

Risk factors for offending include:

■ Having a history of sexually offending behaviour

■ Having a history of domestic violence offending

■ Violent and threatening behaviours

■ Intimidating behaviours including sexual harassment

■ Sexually disinhibitive behaviours

■ Acute drug intoxication e.g. methamphetamines


■ The process for admitting a consumer to any mental

health service should include taking a sexual assault

history. A screening tool to help with this process is

available at Appendix G.

■ It is critical that only staff who have undertaken

training on how to appropriately take such a

history, and respond to disclosures, are

nominated to conduct the associated

assessment. Alternatively, services may wish to

contact their local Sexual Assault Service or another

sexual assault counselling service for support or advice

for the clinician undertaking this assessment.

■ Taking a sexual assault history can be traumatic for

the consumer, so those undertaking the assessment

must be sensitive to the consumer’s feelings and needs

and ensure:

– The assessment is undertaken only when the

consumer is in a stable condition – in acute

admissions, a delay may be required prior to

undertaking the assessment;

– Adequate time is set aside for the assessment – the

consumer should be allowed to proceed at their

own pace; and

– An appropriately private space is allocated to

support the assessment to be undertaken – privacy

and confidentiality are key concerns.

■ Taking a sexual assault history may also be traumatic

for a staff member that has experienced sexual assault

or violence themselves. Staff should be cognisant of

their own feelings about sexual assault and seek

management support to ensure they do not experience

re-traumatisation themselves as a result of their

involvement in the sexual assault history assessment.

■ When possible, family members, carers or friends

should not be present during the assessment so that

influences and distractions are kept to a minimum.

However, the wishes of the consumer must be

respected in this regard – if the consumer feels more

comfortable having a support person attend the

assessment with them, this should not be discouraged.

■ Mental health staff should commence by explaining

to the consumer what will happen with the

information to be collected, how it will be stored and

who will have access to it, which must include the

consumer’s rights under State and Commonwealth

privacy legislation (see Appendix C for further

information).

■ An explanation should be provided to the consumer

regarding why what may be perceived as personal

questions are being asked:

‘So that I can work out the right way to support you

while you are with our service, I need to know a bit

more detail about your life before you came here,

including any experiences you may have had that

made you uncomfortable.’

■ The consumer should also be advised that they have

the right not to answer at the present time but that

the staff member would be available at a future time

should the consumer wish to speak with them.

■ If the consumer identifies a history of sexual assault/

abuse, their experience should be validated:

‘Thank you for telling me about such a difficult

experience.’

‘I’m sure that was hard for you to talk about, but it’s

good that you did.’

■ The consumer’s response should be documented in

their file using the consumer’s own words.

■ An evaluation should immediately be carried out

regarding the present-day level of danger – refer to

Section 5 Responding to a sexual safety incident for

further advice on actions to take when a sexual

assault has been disclosed.

■ If there is no immediate danger, the consumer

should be:

– asked if they have previously disclosed the assault

or abuse and received any support or treatment:

‘Have you had the opportunity to talk to anyone

about this before?’

‘Have you had any support or help to deal with

your feelings about what happened?’

– offered appropriate follow-up and counselling:

‘Sexual assault is devastating in many ways. Let’s

talk about some things we could do to support you.’

■ If support is initially refused, staff should ask the

consumer if they are comfortable to talk again about

their disclosure and support options and set a time

for this.


■ Consideration should also be given to how

re-traumatisation could be prevented. If the past

assault occurred in the current or another mental

health facility, every effort must be made to not place

the consumer back in the same environment and/or

to discuss what might be helpful for the consumer in

decreasing the risk of re-traumatisation.

■ Where there is no disclosed history of previous sexual

assault, clinical practice can still operate from the

premise that this history is a possibility. The consumer

should also be advised that support is available in the

future if they wish to re-visit this topic at a later date:

‘That’s fine – the reason we ask is that we like to

offer people the opportunity to get some support if

they want it.’

■ The admission process will also need to take account

of any history the consumer may have of violent

offending, as this can alert staff to potential problems

and inform care plans to maximise monitoring of

those deemed at risk for violence.

■ Disclosure of alleged sexual assault by a person who

may be working with or who has access to children or

young people requires a report to the Child Protection

Helpline.

4.1.3 Recognising offender tacticsSexual assault can involve a one-off opportunistic event

or a series of ongoing aggressive attacks, but they can be

planned attempts designed by those who perpetrate

sexual assault to coerce another person to provide

sexual favours.

In this situation, deliberate tactics are used to select and

abuse vulnerable or desirable individuals. These tactics

could include:

■ Recruiting these individuals by means of bribes

(money, cigarettes, food, other items) or offering

perceptions of care, love and intimacy

■ Utilising power/positions of power to gain confidence

and trust for the purposes of gaining sexual favours

■ Maintaining this accessibility by using threats to

discourage the individual from disclosing the assault

■ Grooming staff by ingratiating themselves as helpful

and suggesting to staff that the individual they

assaulted is lying

Conditions such as organic brain syndromes may include

sexually aggressive behaviours and require appropriate

supervision where this occurs.

4.1.4 The role of gender sensitivity4

Health policies that are gender neutral assume that men

and women are affected equally or in a similar manner by

ill health. However, because of social and biological

differences, women and men face different health risks,

experience different responses from health systems, and

their health-seeking behaviour and health outcomes

differ (WHO, 2006).

For example, throughout their lifetime, women are more

likely to be affected by physical and sexual abuse

(WHO, 2006)., and have a higher degree of lifetime

exposure to sexual abuse and violence (McGee, 2002).

Nonetheless, there should be no bias or any assumptions

made by services when a sexual assault is reported or

disclosed by a consumer who is a man.

A significant proportion of adults who were sexually

abused as children are male, and male consumers who

are Gay, Bisexual or Transgender (refer to Section 7.4, p. 63)

may have increased vulnerability to sexual victimisation.

Men who are heavily sedated are also more vulnerable to

sexual assault. When consumers who are sedated

experience a sexual assault, the powerlessness they feel

will often be magnified due to their loss of control and

choice in such a situation.

The impact of such an experience for a man will not in

any way be more significant than for a woman, but may

give rise to additional issues because of cultural/social

expectations of men. Evidence suggests that services who

recognise these gender differences within their care

provision, that is those who are ‘gender-sensitive’, achieve

better health outcomes for consumers.

4 Information in this section is drawn from the Women’s Centre for Health Matters paper entitled ‘Gender Sensitive Mental Health Service Delivery’, April 2009.


Gender sensitive practices

In the context of a mental health service, gender-sensitive

practices include:

■ Offering choices about the type of support consumers

receive, and who provides it to them (e.g. a choice

between a male or female doctor, care coordinator

and advocate).

■ Providing opportunities for consumers, but women in

particular, to be involved in their own care and

treatment, including service planning and delivery.

■ Having staff that treat both women and men with

respect, give them time to talk and listen to what

they have to say.

■ Having ‘women only’ spaces within their buildings

(see 4.1.5 Improving the physical environment).

■ Seeing mental health from a holistic perspective, that

is, they consider mental health in the context of the

consumer’s life experiences and personal situations.

■ Taking into account the ‘social determinants of

health’, that is, they acknowledge the way that

women’s and men’s personal circumstances and

socioeconomic status affects their mental health.

■ Recognising a consumer’s strengths and empowering

them to take control of their own lives.

■ Operating in a way that is culturally sensitive to

women from outside the dominant culture.

Gender sensitive seclusion and restraint practices

Where seclusion or restraint is used, there needs to be

additional sensitivity. Re-experiencing trauma or abuse

may trigger the ‘fight, flight or freeze’ response, which

will produce a catecholamine (adrenal) flood. Every effort

should be made to avoid retraumatising or triggering

events in individuals with trauma histories. Where this is

unavoidable, same gender staff should be allocated and

consumers should be adequately clothed.

An audit to assess the current level of gender sensitivity

within the service should be undertaken to determine

priorities for action to increase safety and gender sensitivity.

This audit should be carried out every two years.

4.1.5 Practical security measures

Improving the physical environment

Making improvements to the physical environment of a

facility can have a real and positive impact on addressing

sexual safety issues for consumers. The suggestions

provided here regarding changes to the physical

environment are supported by the Australasian Health

Facility Guidelines.

However, it is recognised that implementing these

changes in some facilities may be difficult. Services should

work towards introducing similar changes to their

facility’s physical environment where the layout of the

existing facility allows this, and taking account of these

suggestions when planning any new facilities.

The NSW Policy Directive Protecting People/Property:

NSW Health Policy/Guidelines for Security Risk

Management in Health Facilities (PD 2005_339) provide

advice for Health Services on maintaining an effective

security program that is based on a structured, ongoing

risk management process, consultation, appropriate

documentation and record keeping and regular

monitoring and evaluation.

Single gender corridors/accommodation and bathrooms

Establishing corridors/accommodation and bathroom

facilities that are specifically for each gender can greatly

improve the feeling of safety for women. Where the

design of the unit features a number of corridors

radiating out from the nurse station, particular corridors

can be designated as either female or male, dependent

upon the needs of the service.

Alternatively, where the unit has a long, circular corridor

with limited visibility, a lockable door could be

constructed at the halfway point of the horseshoe with

one half designed as female and the other male.

Women’s lounges

Women’s lounges can play an important part in helping

women to feel safe and more relaxed as well as providing

a space where supportive contact between other female

consumers and therapeutic relationships with staff can

be promoted.


Existing lounge areas located in women’s corridors could

be designated as women specific or areas which had

previously been used as interview rooms could be used

for this purpose. These lounges could be established as a

sensory /therapeutic room for women with sensory

equipment and a massage chair, or used as a venue for

women specific group activities.

Family visiting areas

The establishment of gender specific areas where

consumers with children and families can visit can

enhance the safety and amenity of inpatient

environments for these groups.

Family visiting areas need to be located near the entrance

to the ward as it is not desirable for children to go through

the main part of the psychiatric unit to visit their parent.

Nurse call buttons

The provision of nurse call buttons enables consumers to

call for staff assistance in case of emergency. Nurse call

buttons could be located in both bedrooms and

bathrooms and promoted to consumers within their

orientation so that they are aware of their existence.

Lockable bedroom doors

Being able to lock themselves in their bedrooms can

greatly contribute to a consumer’s feeling of security at

night. Consumers could either ask to have their bedrooms

locked from the outside, or a mechanism could be utilised

that allows staff to override the locks and gain access

if required.

Sensory motion detectors

Sensory motion detectors installed in all bedrooms can be

activated at night and alert staff if consumers leave their

rooms. These detectors can support staff to monitor

consumer movement and to prevent inappropriate access

to other consumer’s rooms, promoting safety and privacy.

Signage

Clear signage in inpatient units can help to stop

inadvertent accessing of male/female areas. When the

consumer is acutely unwell their usual cognitive abilities

may be impaired, so signage and clear labelling can

support consumers to read environmental cues.

Labels should be easily understood, with accepted symbols

given preference over written language where possible.

Increased vigilance

Increasing vigilance and observation at particular times

when staff are less available is a simple yet effective way

to increase the safety and security of the service

environment. This could include night time, when handover

occurs and during ward rounds, when consumers are

more vulnerable. A constant staff presence is required in

acute inpatient units, including overnight.

Screening of staff

The screening of staff (including volunteers) who apply

for roles within a mental health service must be managed

in accordance with NSW Health’s policies on recruitment

and employment screening.

The introduction of increased screening of staff who

apply for roles within a mental health service, similar to

the working with children check undertaken for those

who work with children, should also be considered as

part of an overall sexual assault prevention strategy.

4.1.6 Maintaining professional boundaries Staff in mental health services, like other public sector

employees, must conduct themselves in a way that promotes

public confidence and trust in their organisation. They

have a duty of care to the consumers utilising the service

in which they work as well as to other staff.

For the purposes of this policy, the definition of staff

includes the following individuals that perform work

within NSW Health facilities:

■ Volunteers

■ Consumer advocates

■ Contractors

■ Visiting practitioners or Medical Officers

■ Students; and

■ Consultants and researchers.

NSW Health Code of Conduct

The NSW Health Code of Conduct (PD2012_018) sets out

the conduct expected of health staff and applies to staff

working in any permanent, temporary, casual, termed

appointment or honorary capacity within any NSW Health

facility, which includes mental health service environments.

The Code of Conduct makes it clear that sexual

involvement with a consumer is a breach of professional

and ethical boundaries:


NSW Health Code of Conduct

Sexual relationships with patients or clients – Section 1.5 I will not exploit my relationship of trust with patients or clients in any way because I recognise that such behaviour is a breach of professional and ethical boundaries and amounts to serious misconduct. I will not have a sexual relationship with a patient or client during the professional relationship.

Relevant legislation

Sexual activity between a NSW Health staff member and

a consumer may constitute a sexual offence under various

sections of the Crimes Act 1900 (NSW) even if the

consumer has not alleged to have been sexually assaulted

and/or appears to have consented to the sexual activity.

Under Section 61 of the Crimes Act, a person is not

considered to have consented to sexual intercourse if:

■ they do not have the capacity to consent, including

because of age or cognitive impairment;

■ they have the mistaken belief that the sexual

intercourse is for medical or hygienic purposes;

■ they are substantially intoxicated by alcohol or any

drug;

■ there has been an abuse of a position of authority

or trust.

Under Section 66F (2) of the Crimes Act, a person who

has sexual intercourse with a person who has a cognitive

impairment, such as a mental illness, and who was

responsible for the care of that person, whether generally

or at the time of the sexual intercourse, is guilty of an

offence. Further information about this Act is provided at

Appendix C.

Under Section 66 of the Crimes Act, any person that has,

or tries to have sexual intercourse with an under 16 year

old, or engages in the ‘grooming’ of children (as defined

in the Act) is guilty of an offence.

Under Section 73 of the Crimes Act, a person who has

sexual intercourse with a child aged between the age of

16 and under 18 when they are in a special care

relationship is guilty of an offence punishable by up to

eight years prison.

Under section 25A of the NSW Ombudsman Act,

allegations against NSW Health staff of sexual assault or

sexual misconduct involving anyone under the age of 18

years are required to be notified by the Chief Executive to

the NSW Ombudsman and investigated by the employer.

Notifications are also required to the Commission for

Children and Young People where there is evidence that

the conduct has occurred. Refer to the NSW policy

directive (PD2006_025) Child Related Allegations,

Charges and Convictions against Employees.

Although the Anti-Discrimination Act 1977 (NSW)

makes sexual harassment a civil not criminal offence,

some types of harassment may also be offences under

the criminal law. These include:

■ physical molestation or assault

■ indecent exposure

■ sexual assault

■ stalking

■ obscene communications such as telephone calls

and letters.

The Medical Practice Act 1992 also places an obligation

on all registered medical practitioners in NSW to report

certain types of misconduct by other registered medical

practitioners to the Medical Council of New South Wales.

This includes sexual misconduct in the practice of

medicine. Further advice about this Act is provided within

Appendix C.


■ A breach of professional boundaries can occur if a

mental health worker displays sexualised behaviour

towards a consumer. This is not limited to criminal

acts such sexual assault but could also include

behaviour such as conducting clinically unjustified

physical examinations.

■ Appendix H expands on the types of sexualised

behaviour that may constitute a breach of professional

boundaries.

■ If a mental health worker becomes sexually attracted

to a consumer and has concerns that this may affect

their professional judgement, they should seek

guidance from their manager or discuss the matter

with a colleague. The development of a culture within

mental health facilities which supports staff to discuss


ethical conduct regularly and to report or raise

concerns/observations is important.

■ If the mental health worker’s manager, or the worker

themselves, believes that their professional judgement

is impaired, they should:

– Find alternative care for the consumer

– Ensure a proper handover of care, where

necessary

– Ensure the consumer does not feel that they are in

the wrong as a result of the handover of care to

another clinician or worker


■ In an inpatient setting, consumers are extremely

vulnerable.

■ Maintenance of professional boundaries in this setting

can be supported by strategies such as using a

chaperone when conducting any examinations of a

physical or intimate nature and organising for female

staff, wherever possible, to treat consumers,

particularly at night.

KEY ACTIONS/POINTS NON-ACUTE/RESIDENTIAL

AND COMMUNITY

■ In a situation where a mental health worker is

attracted to a consumer they must be careful not to

display any sexualised or inappropriate behaviour

towards them. Outside of the inpatient setting,

sexualised behaviour can include:

– Revealing intimate details to a consumer during a

professional consultation

– Giving or accepting social invitations where this is

sexually motivated

– Visiting a consumer’s home unannounced and

without a prior appointment

– Seeing consumers outside of normal practice

– Clinically unnecessary communications

4.2 Consensual sexual activity in an inappropriate context or setting

Sexual activity is a natural and healthy part of life, and for

mental health consumers, reaching out to someone

sexually can be a way to attain reassurance through

affection and touch. However, when it occurs in an

inappropriate context or setting it can be detrimental to

those consumers involved as well as to any consumers

that may witness the activity.

4.2.1 Sexual safety standardsHaving a set of standards that clearly defines appropriate

behaviour for consumers in relation to sexual safety will

help such behaviour to be adopted. An example set of

standards for an acute inpatient and a non-acute/residential

and community setting is provided at Appendix A.

However, services should use these examples as a guide

only – standards should be developed collaboratively with

staff and clinicians, consumers, families and carers,

advocates etc so that they are meaningful and

representative of the service’s own individual ethos.

An annual review of these standards should be

undertaken to maintain their relevance, which should

involve consultation with and input from all of the

above stakeholders.

4.2.2 Addressing sexuality needs Staff should remember that sexuality is a normal part of

life and just because the consumer has a mental illness

does not mean they do not have normal sexual needs. A consumer may need others to give them space and

privacy to express or meet their sexual needs e.g. privacy

to masturbate, watch videos or, in a non-acute inpatient,

rehabilitation or community setting, to have a sexual

relationship.

Masturbation can be a safe alternative to sexual activity

with another person and is appropriate for consumers

receiving treatment in any setting. It carries no risk of

sexually transmissible infection or unwanted pregnancy

and can also be beneficial from a health perspective,

as it promotes the release of the brain’s opiod-like

neurotransmitters (endorphins), which cause feelings of

physical and mental wellbeing.

‘The greatest and most healing service that can be offered to people with psychiatric disabilities is to treat them with respect and honour them as human beings. This means honouring us in our full humanity, including our sexuality and our desire to love and be loved.’

(Deegan, 2001)



■ All mental health services have a responsibility to

develop individual sexual safety standards appropriate

for their particular setting. These must be developed in

consultation with all members of the service e.g. staff

and clinicians, consumers, families and carers etc.

■ These standards should be explained and also

promoted regularly to both consumers and staff so

that they become embedded in service practice.

■ Staff may benefit from training on how to talk about

sexual safety and sexual health issues with consumers

(see Section 3.1 Training and Education for more

information).

■ Education on sexuality and managing sexual

relationships appropriately should also be offered to

consumers so that they understand the positive

expression of sexuality and can distinguish it from

sexual assault.

■ Clear advice must be provided to consumers and their

families and carers regarding the need for expressions

of sexuality, such as masturbation, to be conducted in

a place and at a time that will ensure it remains

private. It will also be important to ensure that the

sexual safety standards for the service include this

stipulation, and that consumers are aware of the need

to adhere to these standards at all times.

■ If masturbation seems to be taking place excessively,

for example if it is interfering with day to day living,

or taking place in inappropriate situations, it may

indicate other issues which need to be addressed.


■ Consensual sexual activity is not supported in an acute

inpatient setting due to the extreme vulnerability of

the consumer/s involved, as well as the vulnerability

of the consumers that may witness any such activity.

Consumers in this setting are generally very unwell,

which makes the consensual, voluntary and mutual

nature of any sexual activity difficult to confirm.

■ Information about this restriction will need to be

included within the information provided to the

consumer and explained, along with the rationale for

its existence, to the consumer and their partner and

family or carer. This should be undertaken with extreme

sensitivity so that the restriction is recognised as being

beneficial for the consumer’s safety and care, which is

paramount, rather than misinterpreted as an action

that is meant to further disempower them.



■ While consensual sexual activity for consumers who

receive treatment in these settings is recognised as a

normal and healthy part of life, consumers can still be

vulnerable to sexual assault and harassment and/or

sexually abusive relationships.

■ Consumers in these settings should be offered

information and access to education that will support

them to understand how to manage sexual

relationships safely or to recognise and appropriately

respond to unwanted sexual advances (see Education

and Training for more information).

■ Consumers should also be provided with clear advice

regarding how to report an incident of sexual assault

or sexual harassment, and encouraged through

education around resilience and building self-esteem

to speak up when they or someone else is being

mistreated.

■ Additionally, consumers in a non-acute/residential

setting must be provided with a copy of the sexual

safety standards for the service, which should be

explained and discussed as required.

4.3 Sexually disinhibited behaviour

Prevention of sexually disinhibited behaviour, whether it is

associated with the consumer’s mental illness or with a

physical condition or disease, such as dementia, will

require correct assessment, vigilance and a high level of

support for the consumer so that the risk of them being

sexually assaulted or assaulting others, being exploited or

exploiting others, and retraumatisation of consumers

witnessing the behaviour, is minimised.

While the behaviour is generally best managed through

the consistent use of simple behavioural techniques, this

approach is less likely to be successful with consumers

who have dementia due to the way in which the disease

impairs new learning. Sexually disinhibited behaviour

occurs at some point in most people with dementia,

particularly those that are men, and is more common

when the disease is mild rather than severe.



■ Consumers will need to be assessed by the senior

clinician at the time of admission regarding both their

vulnerability to sexual assault and exploitation and

their potential to assault or exploit others (see 4.1.1

Assessing vulnerability pg 36). This assessment will

need to consider the likelihood of the consumer

exhibiting sexually disinhibited behaviour, any previous

occurrences and whether the behaviour is linked to

their mental illness or is a result of a physical condition

or disease (e.g. dementia) or substance misuse.

■ Other key factors to consider within this assessment

include:

– The form the behaviour takes and the context in

which it occurs

– The frequency of the behaviour

– Contributing factors or triggers

– Whether the behaviour is problematic and if so

to whom

– The risks associated with the behaviour

■ This assessment will support development of an

appropriate, agreed and comprehensive management

plan. In developing the management plan, services

should take account of:

– The need for a higher level of supervision and

monitoring, and the capacity of the service to

provide this

– How to reinforce appropriate behaviour and

clothing

– Any medication that should be prescribed in the

treatment of the sexual disinhibition

– How to minimise retraumatisation for those who

have experienced a previous sexual assault

– Strategies to distract the consumer should their

behaviour be associated with dementia

– Any changes required to the service setting to

provide safety for other consumers and staff and

privacy for the consumer who may exhibit the

behaviour

– How and what to communicate to the consumer

and their family and carer/s about the behaviour

and how it can be managed

■ Appendix L – Information about managing disinhibited

behaviour provides further advice regarding factors to

consider in the management plan.


KEY POINTS – PREVENTING A SEXUAL SAFETY INCIDENT

Sexual assault and harassment

Assessing the mental health consumer for vulnerability and prior assault

■ The vulnerability of a consumer should be assessed at

the time of admission in all settings. This includes

taking a sexual assault and harassment history.

■ Taking a consumer’s sexual assault history on their

admission to a mental health service is critical to

enable staff to adequately support the consumer,

both in terms of their illness and their sexual safety

while involved with the service. A screening tool to

help with this process is available at Appendix G and

further information is provided in section 4.1.2

■ Only those staff who have received appropriate

training in taking a sexual assault history should

manage this process, or support should be

sought from the local Sexual Assault Service.

■ Where there is no disclosed history of previous sexual

assault, clinical practice can still operate from the

premise that this history is a possibility.

■ Taking a consumer’s history of perpetrating sexual

assault is also vitally important.

Gender sensitivity

■ Throughout their lifetime, women are more likely to

be affected by physical and sexual abuse (Astbury,

2001), and have a higher degree of lifetime exposure

to sexual abuse and violence (McGee et al., 2002).

■ However, a significant proportion of adults who were

sexually abused as children are male, and male

consumers who are Gay, Bisexual or Transgender

(refer to Section 7.4) may have increased vulnerability

to sexual victimisation.

■ Evidence suggests that services who recognise gender

differences within their care provision, that is those

who are ‘gender-sensitive’, achieve better health

outcomes for consumers.

■ An audit to assess the current level of gender

sensitivity within the service should be undertaken to

determine priorities for action to increase safety and

gender sensitivity. This audit should be carried out

every two years.

■ A key strategy to consider in addressing gender-

sensitivity and improving security for consumers is to

establish gender specific accommodation. Other

practical examples of how the physical environment

could be improved to take account of gender-sensitive

practices are provided in section 4.1.4.

Practical security measures

■ Practical security measures have an important part to

play in improving the sexual safety of mental health

consumers in an inpatient or long term residential or

rehabilitation setting and can include:

– Increased vigilance

– Nurse call buttons

– Lockable bedroom and bathroom doors

– Sensory motion detectors

– Clear signage

Staff conduct

■ The NSW Health Code of Conduct (PD2012_018),

which sets out the conduct expected of health staff,

makes it clear that sexual involvement with a

consumer is a breach of professional and ethical

boundaries.

■ Sexual activity between a NSW Health staff member

and a consumer may also constitute a sexual offence

under various sections of the Crimes Act 1900 (NSW).

See section 4.1.6 and Appendix C for further

information.

Consensual sexual activity in an inappropriate context or setting

■ All mental health services have a responsibility to

develop individual sexual safety standards appropriate

for their particular setting. These must be developed

in consultation with all members of the service and

provided to consumers and their families and carers

on admission.

■ Consensual sexual activity is not supported in an acute

inpatient setting due to the extreme vulnerability of

the consumer/s involved, as well as the vulnerability of

the consumers that may witness any such activity.

■ Consensual sexual activity for consumers who receive

treatment outside of the acute setting is recognised

as a normal and healthy part of life. However, any

such activity must adhere to the sexual safety

standards for the service.


■ An assessment will need to be carried out by the

senior clinician at the time of a consumer’s admission

regarding the likelihood of the consumer exhibiting



sexually disinhibited behaviour and any previous

occurrences.

■ This assessment will support development of an

appropriate, agreed and comprehensive management

plan for the consumer, which should consider factors

such as additional supervision, behavioural strategies,

medication etc. See section 4.3 and Appendix L for

further information.

PaGe 34 NSW HealtH Sexual Safety of Mental Health Consumers Guidelines



There are four main ways that sexual assault involving a

consumer may come to the attention of another person:

■ the consumer tells someone they have been sexually

assaulted;

■ the sexual assault or exploitative behaviour is

observed by a third party;

■ the behaviour of the consumer changes significantly; or

■ the consumer complains of physical symptoms or they

are observed by another person.

5.1.1 When there is disclosure or acknowledgement of sexual assault or harassment

Disclosure means telling another person about an incident

of sexual abuse, sexual assault, or sexual harassment, or

acknowledging to another person that this has occurred,

whether the incident is recent, past or ongoing.

Disclosure or acknowledgement is distinct from making a

report or allegation (even if sometimes they are one and

the same event). Disclosure is about support-seeking,

while reporting to Police and making allegations are

formal mechanisms to bring an incident to the attention

of law enforcement and other agencies. The following

information provides guidance about the key actions to

take when a disclosure of sexual assault is made. These

actions are summarised in Appendix I and a quick

checklist provided at Appendix J.

Acknowledging and affirming the disclosure


■ Disclosing an incident of sexual assault or harassment

can be traumatic.

■ The fear of not being believed, an issue for many who

are assaulted, may be heightened for people with a

mental health problem or mental illness. The stigma

that surrounds mental health problems or mental

illness can result in a consumer feeling their

experiences are not legitimate.

■ When a consumer discloses past, recent or ongoing

sexual assault or harassment it is essential that staff

believe and validate the consumer’s experiences rather

than make assumptions about what has happened, or

how the consumer feels about the incident

■ Staff have a responsibility to initiate and adhere to the

formal process outlined within these guidelines to

respond to disclosures of sexual assault or harassment

until assessment of the consumer’s clinical mental

state determines otherwise (see advice under

Exploring the Disclosure).

■ Implicit in the provision of a caring and effective

response is the understanding that no-one ever

deserves to be sexually assaulted or harassed. A

judgmental or indifferent response to a disclosure can

negatively impact the recovery process.

Exploring the disclosure


■ The consumer who has disclosed the sexual assault

should immediately be provided a safe, quiet and

private space.

■ Staff should let the consumer tell them in their own

words and at their own pace about their experience

and concerns, and unnecessary or repeated

questioning should be avoided as this may cause

distress.

■ Once they feel able, the consumer should be gently

encouraged to provide staff with brief details about:

– the name of the alleged perpetrator

– where and when the alleged assault or harassment

took place

– any injuries or other concerns that may require

medical attention

■ Any questioning that is required should be ‘open not

closed’ questioning to prevent any risk of contamination

of evidence if a matter proceeds to court. Examples of

open-ended questions are, ‘Can you tell me more?

What happened next? Did anything else happen?

When did this happen?’ and so on. These are

clarifying questions.

SECTION 5

Responding to a Sexual Safety Incident


■ Consumers may at times retract a disclosure. This may

be due to a failure of staff to believe them, and/or

because of undue pressure, with negative outcomes

for a consumer who persists with a disclosure.

■ In the case of individuals who have a refugee

background, mistrust of authorities such as health

services due to previous political persecutions or

torture may result in a retraction.

■ A retraction does not mean that an incident of sexual

assault or harassment did not occur and that no

assessment should take place.

■ Pursuing the issue may be difficult without clear

support. However should a consumer retract a

disclosure, the incident should still be reported and

recorded (see Reporting and Recording). Should the

disclosure involve a NSW Health staff member, the

reasons for the disclosure may need to be considered

and an internal investigation still completed with a

recorded outcome.

■ Disclosures, where the alleged perpetrator is a NSW

Health employee, must be notified to the relevant

manager and managed in accordance with NSW

Health policies for managing child related and criminal

allegations against employees.

■ Where the disclosure relates to a risk of significant

harm to a child or group of children, the Child

Protection Helpline must be notified.5


■ An assessment of the consumer’s clinical mental state

must be carried out by the senior clinician (where not

involved in the allegation) within 24 hours.



■ An assessment of the consumer’s clinical mental state

must be carried out by the senior clinician (where not

involved in the allegation) within 48 hours.

5 The NSW Government Mandatory Reporter Guide (including a decision tree for sexual assault) can be found at: http://dr.sdm.community.nsw.gov.au/mrg/app/summary.page;jsessionid=B13F2B7E7C8AFBC0DE2854A2F1E2F6AC

Establishing and maintaining safety


When the alleged perpetrator is a consumer

■ If the consumer who has disclosed the sexual assault

wishes to be moved to another room or unit/facility/

service, this request should be accommodated where

possible.


and the person who has been named as the perpetrator

should be separated. The alleged perpetrator should

be moved to another facility, unless the consumer

who has disclosed the assault specifically requests

otherwise or there are other extenuating circumstances.

This helps to address the feelings of self-blame that

victims/survivors of sexual assault often experience.

■ If staff have reason to believe the alleged perpetrator

poses some ongoing risks to the consumer who has

disclosed the assault or other consumers, all

reasonable steps should be taken to minimise risk,

including a comprehensive ongoing risk management

strategy to prevent any harm.

■ Where the alleged perpetrator is a consumer and the

person who has disclosed the assault is a child, for

example a visiting family member, a report to the

Child Protection Helpline (phone 13 36 27) should be

made, in addition to taking steps to minimise further

risk to the child, or other consumers or staff in the

service. Where the consumer who has disclosed the

assault is a young person, a report may be made to

the Child Protection Helpline. Reports should be made

in accordance with the NSW Health Frontline Policies

and Procedures for Child Protection and Wellbeing

(revised procedures being finalised at the time of

printing).

When the alleged perpetrator is a NSW Health

employee

■ Allegations or disclosures of sexual assault against

NSW Health staff members must be reported to a

relevant line manager and to the NSW Police Force or

to the Child Protection Helpline depending on the

current age of the victim.

■ Allegations of sexual misconduct or sexual assault

against NSW Health staff members involving under 18

year olds must be reported to a relevant line manager

and will require a notification to the NSW Ombudsman.


■ An immediate risk assessment must be conducted to

determine whether there is any risk to consumers or

employees and whether the staff member subject to

the allegation requires relocation, supervision or

suspension. Once an initial risk assessment is

completed, the service must liase with NSW Police or

Community Services regarding the commencement of

an internal investigation.

■ Any allegations that involve NSW Health staff members

must be managed in accordance with the relevant

policies for managing child related or criminal allegations

against staff. And for managing the disciplinary process.

■ A decision regarding whether an entry is required on

the NSW Health Service Check Register must also be

considered.

■ Where an allegation involves the conduct of a health

practitioner or health service provider that is not a

criminal offence, and does not involve a consumer

under 18 years of age, the NSW Health Policy

Directive concerning the management of a complaint

or concern about a clinician (Complaint or concern

about a clinician – principles for action PD2005_007)

should be consulted and appropriate action should be

taken to inform registration authorities and other

bodies, as relevant.

When the alleged perpetrator is a family member

or person in a position of continuing power or

authority over the consumer

■ Staff should consult with their supervisor or appropriate

senior manager to explore how to establish and

maintain the safety of the consumer in these particular

circumstances. This may include approaching the

Guardianship Tribunal about the concerns or seeking

advice from the Police about obtaining an

Apprehended Violence Order (AVO) for the consumer.

Securing any evidence


■ If the sexual assault has occurred within the last seven

days, staff should immediately secure any evidence

related to the sexual assault pending Police

involvement, or until the consumer disclosing the

sexual assault has made a definite decision not to

involve the Police. At the first opportunity, the senior

manager or supervisor should also consult with the

local Sexual Assault Service, being mindful to

maintain the privacy of the consumer.

■ Securing the evidence will involve:

– Keeping any clothing that the consumer who

has experienced the sexual assault was wearing at

the time of the assault – these should only be

handled by the consumer to minimise DNA

contamination and kept in a safe place in a paper,

not plastic, bag and not washed. Appropriate bags

can be obtained from the local Sexual Assault

Service.

– Securing the location of the assault if possible to

prevent any evidence being disturbed.

– Securing any CCTV footage of the incident area

– this footage will be required by investigators.

Offering support and options

It is not uncommon for someone who has experienced a

sexual assault to minimise their feelings about an assault

or to feel that they do not deserve any assistance.

However, reassurance that there are services and

professionals able to provide assistance and advocacy is

important. Support can help to validate the consumer’s

experience, and assist them to take appropriate steps to

deal with a sexual assault.

A sexual safety incident, particularly an assault, can also

be stressful for staff. Support and an opportunity to

debrief should be offered to the staff member to whom

the disclosure was made, particularly when this is a

consumer advocate or worker, and to all staff connected

with the incident. The local Sexual Assault Service may be

able to help with this.


■ Staff should calmly outline the available options so

that the consumer who has experienced the sexual

assault can make an informed decision about how

they want to proceed. It is important that they do not

feel pressured to take a particular course of action.

Information about available options is provided at

Appendix D.

■ The consumer who has experienced the sexual assault

should be informed that they can choose a support

person, such as a consumer worker, family member,

friend or a staff member that they know and are

comfortable with.

■ If the consumer does not wish to inform their carer or

family, their wishes must be respected, within the

limits of legislation. If the consumer’s carer and family

are informed, they can be referred independently to


the local Sexual Assault Service to learn how they can

best support the consumer.

■ An interpreter should be made available for the

consumer who has experienced a sexual assault who

has communication difficulties, for example a

consumer with limited English language proficiency or

those who are deaf or have a hearing impairment.

■ Staff are not required to report a sexual assault to

Police if this is against the wishes of the consumer

who has experienced a sexual assault, except where:

– the alleged perpetrator is identified as a NSW

Health staff member, or

– the consumer is a child under the age of sixteen,

or

– the consumer does not have the capacity to make

an informed decision and the senior clinician has a

duty of care to act in the consumer’s best interests.

■ All allegations that involve possible criminal conduct

involving a staff member must be reported to the

NSW Police Force. Where the NSW Police Force

undertakes or is undertaking an investigation, an

ongoing liaison should be maintained to ensure that

investigations are coordinated and re-interviewing is

minimised or prevented.

■ If the consumer decides to report the assault, staff

should offer to immediately refer the consumer to

their local Sexual Assault Service and/or arrange for

the consumer to talk to the on-call sexual assault

counsellor about their options and what services the

Sexual Assault Service can provide – including a

medical and/or forensic examination, crisis and

ongoing counselling and support, and assistance

reporting to the Police.

■ If a referral is made to a Sexual Assault Service, staff

should inform the on-call counsellor about the

consumer’s capacity to consent, any guardianship

arrangements that are in place, whether an

interpreter or other support services are required, and

whether the consumer has any injuries or medical

issues that require immediate treatment.

■ At all times, however, staff should be guided by the

wishes of the consumer who has disclosed the sexual

assault, where possible. It is important that the

consumer retains control over decisions, including the

decision to report the crime to the NSW Police Force

or to contact the Sexual Assault Service.

■ This does not prevent the service from consulting with

the NSW Police Force and the Sexual Assault Service

as long as the consumer is de-identified.

The consumer who has experienced a sexual assault should be informed that:

■ They can have the support of a consumer worker, family member, friend, staff member, care coordinator, advocate or other significant person in any interviews.

■ They can have access to the local Sexual Assault Service (SAS) for counselling, help in completing a Police report and legal representation, or to simply assist them to make informed choices and decisions.

■ Their right to privacy and confidentiality, within the limits of legislation, will be respected at all times.

■ Their informed decisions will be respected at every stage of the process.

■ It is their decision whether or not to involve the Police and participate in a Police investigation, except in certain circumstances (e.g. where the alleged perpetrator is an employee of the service – reporting is mandatory in these circumstances).

Adapted from the VIC Chief Psychiatrists Guidelines –

Promoting sexual safety, responding to sexual activity

and managing allegations of sexual assault in adult

acute inpatient units

Organising medical care

It is important that consumers who disclose sexual assault

are offered medical assistance to treat any physical or

psychological injuries, regardless of whether the assault

or harassment was recent or occurred some time ago.

Medical care can involve managing physical injuries

(including concerns about pregnancy or sexually

transmitted diseases), psychological impacts, and possible

forensic examinations (to collect any physical evidence

that may be used if criminal charges are laid).


Assessment and treatment of physical injuries


■ The consumer who has disclosed a recent sexual

assault should be encouraged to seek immediate

medical assistance to identify and treat any physical

injuries they may have sustained as a result of the

assault.

■ Provided the consumer has given permission for the

service to contact them, the local Sexual Assault

Service can organise this. If permission has not been

given for Sexual Assault Service involvement, the

Sexual Assault Service can still be consulted regarding

current clinical practice to ensure the most effective

treatment is provided.

■ Where appropriate, the risk of infection or pregnancy

should be discussed with the consumer, and testing

recommended. (It should be noted that morning after

pills are most effective taken within 72 hours of

the assault.)

■ Follow-up medical assessments for the consumer are

recommended at two weeks, three months and six

months post assault and services should liaise with

the local Sexual Assault Service involved, or the

consumer’s GP if relevant, regarding appointments for

these assessments to occur. Further information about

the medical assessments required when a person has

been sexually assaulted is provided at Appendix K.


■ If the consumer who has disclosed the sexual assault

decides not to involve the local Sexual Assault Service,

the service itself will need to consider the medical

needs of the consumer and organise a medical

assessment, with the consumer’s consent.

■ Staff must ensure that any assessment of or medical

treatment for the consumer in the acute inpatient

setting is carried out with the consent of the

consumer, where they have the capacity to provide

this (see Assessing Capacity for further information).



■ In this setting, the consumer who has disclosed the

sexual assault should be supported to see their local

GP, Sexual Assault Service or other support group if

they choose to do so.

■ If the consumer is not in urgent need of medical

treatment, but is assessed as at risk of significant

harm to themselves (i.e. due to suicide or dangerous

self-neglect) they may require involuntary admission

to hospital under the Mental Health Act.

■ In any such situation, extreme sensitivity must be

applied, with careful consideration of the importance

of minimising any risk of re-traumatisation.

Counselling for psychological injuries


■ A consumer who has disclosed a sexual assault can

access specialised counselling through their local Sexual

Assault Service or may address their experiences of

sexual assault or harassment through counselling with

a range of different health providers such as mental

health staff, counsellors with the Approved Counselling

Scheme (Victims Services, Justice and Attorney-General),

and counsellors in private practice.

■ Counselling can take a variety of forms, and consumers

interested in counselling can choose between options

such as individual, group therapies, family therapy

and/or opt for formal or more informal support.

■ Staff should explore with, and support, the consumer

to access the types of counselling and social support,

if any, that the consumer thinks will be useful and

beneficial to help them to deal with their experience

of sexual assault or harassment.

■ Social support in a group setting is often valuable for

people who have experienced sexual assault or

harassment especially when they have little or no

existing social support as usually:

– it helps to decrease the isolation that someone

who has experienced a sexual assault often feels;

– it provides a supportive atmosphere;

– attendees are encouraged to share their experiences;

– it helps those who have experienced a sexual

assault to establish their own support network.

■ Staff may wish to establish a sexual assault support

group in their facility and/or contact their local Sexual

Assault Service to collaborate in establishing and

co-facilitating a group for consumers who have

experienced sexual assault.

■ Mental health services should be familiar with the full

range of formal and informal resources that are

available locally for victims/survivors of sexual assault

and harassment. It is the role of the mental health

worker to help consumers identify and choose the

most suitable option(s) for their particular requirements.


Organising a forensic examination


■ A forensic examination is a medical examination that

can only be conducted by specially trained doctors

and nurses. The purpose of the examination is to

collect any physical evidence that may be used as

evidence against the alleged perpetrator if criminal

charges are laid after a sexual assault has occurred.

■ Specially trained doctors and nurses are available at all

Sexual Assault Services to provide medical and

forensic examinations for victims of sexual assault.


should be able to consent to a forensic examination

and make decisions about whether or not to proceed

with making a report to the Police (assuming the

consumer has been provided with the relevant

information).

■ However, the consumer may not have the capacity to

make informed decisions at this time and a medical or

forensic examination, although agreed to by the

consumer, may not be in the consumer’s best interest.

In such instances a medical or forensic examination, if

there are no obvious injuries, can wait until the

person is able to give consent.

■ The local Sexual Assault Service counsellor can advise

on consent issues in this context and forensic

examination timeframes.

■ If the consumer decides to undertake a forensic

examination, they can request that a person of their

choice – such as a friend or social worker – supports

them during the examination.

■ It is important to remember that accessing medical

care and undergoing a forensic examination does not

mean that the consumer has to report the assault to

Police or request further action.


■ Where the senior clinician is satisfied that a forensic

examination can be performed as an addition to

appropriate medical treatment, the procedure is a

minor medical treatment to which a ‘person

responsible’ can provide a valid substitute consent,

provided there are no objections from the consumer.

■ If the senior clinician considers there is no medical

reason why an examination should be undertaken

and the only reason for such an examination is the

collection of forensic evidence, the procedure is not

medical treatment and the ‘person responsible’ has

no authority to consent to such an examination.

■ In such circumstances, an application should be made

to the Guardianship Tribunal for the appointment of a

Guardian who is authorised to give (or withhold)

consent to a forensic examination (see Assessing

Capacity for further information).

■ However, a sexual assault forensic examination will

never be performed on a person who is unwilling to

proceed with the examination, even if the necessary

consent is obtained.

■ Additionally, the consent for a sexual assault forensic

examination does not include consent to release the

Sexual Assault Investigation Kit (SAIK) to Police. It is

preferable, where possible, to wait until the consumer

can make their own decision about releasing the

forensic protocol and proceeding with the report to

Police.

■ A decision about whether the consumer has

recovered the capacity to make informed consent in

relation to the release of the kit will be determined by

the treating mental health practitioner and the

consumer. The process and basis of this decision will

be documented in the consumer’s file.

■ If the consumer does not recover the capacity to give

informed consent, only a guardian appointed by the

Guardianship Tribunal will have the authority to

determine whether to release the SAIK or not.

■ Due to the issue of re-traumatisation and the capacity

for consent around complex issues it is recommended

that consent not be given for the taking of

photographs for forensic or educational purposes.



■ Outside of the acute setting, consumers who have

disclosed a sexual assault should be encouraged and

supported to contact the local Sexual Assault Service

or the local hospital, or to provide staff with

permission to do so, regarding a forensic examination.

Assessing capacity to make informed decisions

Whether the consumer has the capacity to make

informed decisions in relation to an incident of sexual

assault or harassment, including reporting to Police, is an

important consideration. The capacity to make informed

decisions requires not only cognitive function, but also

the ability to process information in a meaningful way.


KEY ACTIONS/POINTS FOR ALL SETTINGS6

■ The treating team will need to evaluate:

– The consumer’s capacity to understand the process

of reporting an allegation to the Police, and what

it might mean for them.

– The consumer’s capacity to process and

communicate information and effectively exercise

their rights.

– The consumer’s suitability to attend for Police

interview and any likely detrimental effects on their

mental health.

– The consumer’s capacity to collaborate with an

investigation.

■ This will assist the senior clinician to form an opinion

about the consumer’s wellness, the likely impact of

Police interview on their mental state, and any other

clinical considerations.

■ However, individual values and beliefs can vary

considerably from person to person and one

individual’s decisions may not always appear rational

to others. It is important that mental health staff do

not judge a consumer as not competent to make their

own decisions simply because they do not agree with

their views or decisions.

■ Basic principles to be used in assessing a person’s

capacity include:

– Always presume a person has capacity

– Capacity is decision specific

– Don’t assume a person lacks capacity on

appearances

– Assess the person decision making ability not the

decision they make

– Respect a person’s privacy

– Substitute decision-making is a last resort

(New South Wales Attorney General’s Department

Capacity Toolkit May 2008 p. 27)

■ It should also be noted that a consumer’s capacity

may fluctuate, so decisions regarding what action to

take in response to an incident of sexual assault or

harassment should be delayed if possible until the

consumer’s capacity is restored.

■ If there are doubts about the consumer’s capacity to

make an informed decision, a formal mental health

assessment may be required.

■ While a consumer may permanently lack the capacity

to make medical decisions, they may still be able to

6 Information adapted from the Victorian Government Department of Health Promoting sexual safety, responding to sexual activity, and managing allegations of sexual assault in adult acute inpatient units

contribute meaningfully to a discussion about what

actions they wish to take in response to an incident of

sexual assault or harassment. The consumer’s

nominated primary carer, if they have one and they

are not the alleged perpetrator, can also support

them with decision making.

■ Special attention is required in the case of involuntary

consumers under the Mental Health Act 2007.

■ Involuntary status refers to the consumer’s capacity

to consent to psychiatric treatment and does not

automatically extend to a consumer’s capacity to

make decisions about non-psychiatric medical

treatment or other wellbeing or lifestyle matters.

■ Where it is determined that an involuntary consumer

does not have capacity to make an informed decision,

urgent application can be made for a Guardian to

make some decisions in the consumer’s best interests

or the consumer’s ‘person responsible’ can be

contacted.

5.1.2 When sexual assault or harassment is suspected but not disclosed

Sometimes staff may have a suspicion that sexual assault

or harassment has occurred even when there has not

been a disclosure by the consumer. While staff should be

cognisant of the signs that could indicate this, it should

be stressed that it is extremely difficult to tell, by

observation alone, if someone has been the victim/

survivor of sexual assault or harassment.

If a staff member suspects that a consumer has been

sexually assaulted or harassed, it is important to ask the

consumer directly (refer to Section 4).

Indication of possible recent sexual assault

Psycho-social

Psycho-social behavioural responses may occur

immediately or within a few weeks of the sexual assault

and may vary in their intensity, receding and intensifying

at different times. Any individual might experience some,

all or none of these responses and these will be expressed

differently from one person to another. These responses

could include:

■ Significant changes in the consumer’s usual behaviour

or affective state

■ Acute stress response

■ Avoidance of specific settings or individuals

■ Withdrawal

■ Sleep disturbances

■ Changes to eating habits (e.g. refusing to eat)


■ Regression

■ Excessive crying

■ Non-compliance or over-compliance

Physical

The incidence of physical injury related to sexual assault is

low and the extent does not equate with the extent of

psychological trauma. However, physical signs that may

indicate a recent sexual assault include:

■ Bruises, bleeding or other signs of physical trauma

■ Foreign objects in genital, rectal or urethral openings

■ Genital, urethral, or anal discomfort (e.g. itching,

inflammation, infection)

■ Sexually transmitted infection

■ Torn or missing clothing

■ Pregnancy

■ Semen stains on clothing, particularly on women’s

clothing

Indication of possible prior sexual assault

For some people, their psycho-social reactions persist or

worsen over time, or may appear some time after the

assault or abuse has occurred. Some reactions that could

indicate prior sexual assault include:

■ Depression

■ Flattened or hyper-aroused affect

■ Flashbacks and/or nightmares

■ Response to ‘triggers’ (i.e. any sensory stimulus that

evokes a fear response related to a sexual assault)

■ Substance misuse

■ Atypical attachment

■ Poor self-esteem, including body image issues

■ Eating disorders

■ Fear of a medical or dental examination

■ Self-harming behaviour e.g. cutting, burning, head-

banging, severe scratching

■ Suicidality

■ Sexually inappropriate behaviour

■ Somatic health responses e.g. gynaecological

problems, gastro-intestinal problems

Consumers who were sexually abused as children, or in

other settings, may be retraumatised when they enter a

new facility, or by events at a facility. Mental health staff

should note the following ‘triggers’ that may suggest

earlier sexual abuse, and may cause retraumatisation:

■ Being out of control in a situation

■ Derogatory or insensitive comments about people

who have experienced a sexual assault

■ Television and movie violence

■ Seeing someone who looks like assailant

■ People touching or standing close without permission

■ Being hugged or touched by any adult

■ Being in a vulnerable position or situation

■ Sexual advances

■ Reading or hearing about other sexual assaults

■ Feeling that people are staring

■ Action, smell, sound, that reminds the consumer of

the assailant or the place where assaulted

Reasons for non-disclosure

Consumers may not disclose sexual assault or sexual

violence for a number of reasons, including:

■ Fear of disbelief, or blame

■ Past negative experience of disclosure

■ Impact on family and significant others

The relationship between the consumer who has

experienced a sexual assault and the perpetrator can also

influence disclosure as the consumer may have a sense of

responsibility to protect the perpetrator.


■ If a staff member suspects that a consumer has been

sexually assaulted they should gently ask the person

and offer help.

■ However, in some cases, the consumer may not wish

to confirm they have been sexually assaulted, even if

the staff member has reasonable evidence to suggest

that such an event has occurred.

■ The staff member should discuss what they have

observed with the consumer and explain why they

continue to be concerned about the consumer’s

health and safety. The consumer should also be

advised that they have the right not to discuss the

issue at the present time but that the staff member

would be available at a future time should the

consumer wish to speak with them.


■ Educative information about sexual assault and

harassment should be offered along with advice

about the role of the local Sexual Assault Service and

how to contact them.

■ Support to contact the local Sexual Assault Service or

another specialist support organisation should also be

offered.

■ Even if the consumer does not confirm that a sexual

assault has taken place, the suspicion of sexual assault

should be reported internally via the available

mechanisms (see Reporting and recording

requirements – page 66).


■ In an inpatient setting, the senior clinician has a duty

of care to consider and act in the consumer’s best

interests. Staff should refer to the information within

Assessing capacity to decide whether a consumer is

able to make informed decisions about their options

regarding a sexual assault.

■ Where an involuntary consumer has been assessed by

the senior clinician and the consumer does not have

the capacity to make informed decisions in relation to

a disclosure of sexual assault, the senior clinician has a

duty of care to report the allegation to Police.

■ Where an involuntary consumer has been assessed

and does have capacity, their wishes must be

respected, unless legislatively prohibited e.g. when

the alleged perpetrator is a member of staff.



■ Outside of the acute setting, the consumer’s wishes

must be respected. The senior clinician should however

take the necessary steps to protect the consumer’s

interests should they change their mind over time.

■ This may involve the senior clinician ensuring the

incident is well documented and any objective

evidence is collected and preserved should the person

wish to proceed at a later date. The consumer should

be fully informed about the actions that will be taken

and the reasons behind them.

■ Follow-up care should also be provided including

ongoing counselling about the event to understand

their wish not to report, and help them exercise their

rights, which may still include a choice not to proceed

with any further action.


5.2.1 Understanding consent and capacity

When sexual activity occurs, in all cases it must be easily

recognised as consensual, voluntary and mutual in nature

and the persons involved must have given informed

consent.

Consent exists only when a person freely and voluntarily

agrees to engage in sexual intercourse and can only be

said to be valid if the person knows what they are

consenting to, and has a real option of saying yes or no.

Additionally, most jurisdictions in Australia recognise that

there is no consent where the person who has agreed or

submitted to the sexual act does not have the capacity to

understand the sexual nature of the act.

Other factors which might make a person’s consent to

sex invalid include:

■ If a person does not really understand what is being

asked

■ If a person does not know they have the right to

refuse sex

■ If a person does not know how to refuse sex

■ If a person is afraid to refuse sex

■ If a person does not know that sex is not meant to be

painful or uncomfortable

■ If a person does not know that he or she is being

exploited when a reward/incentive or payment for sex

is used

■ If a person does not know that some relationships are

illegal, such as those within families, or between

health staff and consumers.

It is important, therefore, for mental health staff to have

an understanding of the capacity of the consumers under

their care to consent to sexual activity. When this capacity

is in doubt, an assessment should be undertaken of the

consumer’s clinical mental health status, communication

skills and current level of knowledge and understanding

regarding sexual and personal relationships.

Specific questions to be considered within such an

assessment include:


■ Is the consumer aware of the relationship?

Is the consumer aware of who is initiating the sexual

contact? Does the consumer believe that the other

person is a spouse, or do they know the other

person’s identity and intent? Can the consumer state

what level of sexual intimacy with which they would

be comfortable?

■ What is the consumer’s ability to avoid

exploitation? Is the behaviour consistent with

formerly held beliefs or values? Moreover, does the

consumer have the capacity to say no to uninvited

sexual contact?

■ What is the consumer’s understanding of the

parameters and impact of the relationship? If the

consumer realised that the relationship may be time

limited, can they describe how they will act if the

relationship ends?

Further information regarding what the law in NSW says

about consent is provided at Appendix C – Crimes Act

2000.

5.2.2 Staff attitudesThere are situations where consumers may be engaging

in activities which other people view as morally wrong or

not in the best interests of the individual.

Mental health staff are not expected to judge the

rightness of any sexual activity that has taken place.

However, they are expected to be sensitive to the

possibility of assault and abuse, and to raise any concerns

with their line manager or the senior clinician if they

believe a consumer’s behaviour is putting them at risk.


■ It can be difficult for staff to decide whether sexual

activity involving a consumer is consensual or should

be recognised as an assault. An assessment that is

specifically about the consumer’s abilities to

understand sexual and personal relationships, and

therefore provide informed consent, will support staff

in this regard. This assessment must be recorded in

the consumer’s collaborative care plan and reviewed

on a regular basis.

■ When assessing whether consent has been provided,

evidence of mutuality should also be considered to

rule out coercion. Factors to consider could include:

– both parties seeking each other out

– spending spare time together

– shared resources

– shared leisure activities

– restriction of activities with other potential

partners

■ If the sexual activity is deemed to be assault or

harassment, the guidelines for responding to sexual

assault or harassment will need to be followed.

■ Even where the sexual activity is deemed consensual,

staff should be cognisant of the need to provide

counselling or other additional care or treatment, for

either the participants or those who have witnessed

the activity, to avoid retraumatisation for those who

have experienced prior sexual assault or harassment.

■ Staff will also need to ensure that the sexual safety

standards for the service are reiterated to the

consumer and their families and carers as well as the

requirement to adhere to these.


■ In this setting, care should be taken to ensure that the

consumer or consumers involved understand that

sexual activity is not supported due to the

vulnerability of those in care.



■ Consumers in non-acute/residential and community

settings have the same rights as the rest of the

community to engage in sexual activity so long as

both parties consent, demonstrate capacity to make

decisions and any activity takes place privately.

■ In a non-acute/residential setting, where one or both

individuals lack the capacity to consent, mental health

staff should work with these individuals to explore

solutions. Where a sexual relationship is established,

staff should monitor the general wellbeing of the

consumers involved and attempt to obtain an

understanding of how this relationship may be

impacting upon their wellbeing.


When a consumer exhibits sexually disinhibited behaviour,

it can be confronting and embarrassing for those who

witness the behaviour, or for those to whom the

behaviour may be directed. Reassurance should be

provided to both the consumer who is exhibiting the

behaviour as well as to the person or persons who may

have been offended by this behaviour.


Sexual disinhibition can also impact on the consumer’s

existing intimate relationships, their self-esteem and their

reputation – the consumer may take actions that they would

not ordinarily take while in a well state, such as engaging

or offering to engage in sexual activity with someone.

Staff should try not to overreact to the behaviour – a

gentle and patient approach should be adopted,

particularly where the consumer has dementia, as they

will often be anxious and need additional reassurance.

If there is any real threat to the safety of other consumers

or staff from the consumer exhibiting the behaviour, the

emphasis must be on protecting others.


■ When sexually disinhibited behaviour occurs, it is

important to give clear, simple and unambiguous

feedback. Staff cannot assume that a consumer will

recognise hints that their behaviour is not appreciated.

■ Staff should take the consumer who has exhibited the

behaviour aside and gently yet firmly provide this

feedback, which may need to include matter-of-fact

advice regarding unspoken rules about appropriate

social behaviour.

■ The consumer’s understanding of what has been said

should be checked by asking them to repeat the

information. Staff should use this approach with care

and sensitivity to avoid being interpreted as patronising.

■ If the consumer does not already have a plan in place

to manage their disinhibited behaviour, this will need

to be developed (see section 4.3 and Appendix L for

further information). After an incident of sexual

disinhibition, any existing management plan for the

consumer/s involved should be reviewed and updated

to take account of the need for further actions or

strategies.

■ Staff will also need to ensure this updated plan is

agreed with and communicated to all mental health

staff involved in the consumer’s care as well as to the

consumer’s family and carer so that the consumer is

receiving a consistent message about their behaviour.

■ Where a consumer has engaged in sexual activity

with someone other than their regular partner as a

part of their sexual disinhibition, they may require

counselling along with their family, carer or friends.

They may also require sexual health advice or treatment.

■ If a consumer has sexually assaulted another

consumer, or been assaulted themselves, as a result

of their sexual disinhibition, the protocols for

responding to this type of sexual safety incident

should be followed.


KEY POINTS – RESPONDING TO A SEXUAL SAFETY INCIDENT

Sexual assault and harassment

When there is disclosure or acknowledgement of sexual assault or harassment

■ Key actions to take when a disclosure of sexual

assault is made:

– Acknowledge and affirm the disclosure

– Explore the disclosure

– Establish and maintain safety

– Secure any evidence

– Offer support and options

– Assess capacity to make informed decisions

– Organise medical care

■ See Section 5.1 for further information, as well as

Appendix I and J.

■ In relation to reporting to the NSW Police Force,

contacting the local Sexual Assault Service or

informing the consumer’s family or carer, the wishes

of the consumer who has disclosed the sexual assault

must be respected at all times, except where:

– the alleged perpetrator is a NSW Health staff

member; or

– the consumer does not have the capacity to make

an informed decision.

■ The Child Protection helpline must be notified when

there is risk of significant harm to a child or group of

children.

■ Relevant line managers must be informed of

allegations involving NSW Health staff members.

When sexual assault or harassment is suspected but not disclosed

■ Staff should be cognisant of the signs that could

indicate that sexual assault or harassment has

occurred. See Section 5.1.2 for further information.

■ If a mental health worker suspects that a consumer

has been sexually assaulted or harassed, it is

important to ask the consumer directly. See Section 4

for further information.

Consensual sexual activity in an inappropriate context or setting

Understanding consent

■ When sexual activity occurs, in all cases it must be

easily recognised as consensual, voluntary and mutual

in nature and the persons involved must have given

informed consent.

■ Further information regarding what the law says

about consent is provided at Appendix C.

Staff attitudes

■ Mental health staff are not expected to judge the

rightness of any sexual activity that has taken place.

However, they are expected to be sensitive to the

possibility of assault and harassment.

■ An assessment that is specifically about the

consumer’s abilities to understand sexual and

personal relationships will support staff in this regard.

See 5.2.2 for further information.


■ When a consumer exhibits sexually disinhibited

behaviour, staff should provide clear and

unambiguous feedback about the inappropriateness

of the consumer’s actions in a gentle yet firm manner.

■ A management plan will need to be developed to

manage any further behaviour of this nature, which

should be communicated to all staff as well as the

consumer’s family and carer – see section 4.3 and

Appendix L for further information.

■ If a consumer has sexually assaulted another

consumer, or been assaulted themselves, as a result of

their sexual disinhibition, the protocols for responding

to this type of sexual safety incident should be

followed.

PaGe 46 NSW HealtH Sexual Safety of Mental Health Consumers Guidelines


SECTION 6

Reporting and Recording

Appropriate reporting and accurate recording are an

essential component of an effective response to a sexual

safety incident that involves a mental health consumer.


6.1.1 Reporting

Internal

When a sexual assault or harassment has been disclosed

or reported, the incident must be reported as follows:

The Staff Memberinforms

The Team Leader/Nursing Unit Managerinforms

The Senior Managerinforms

Mental Health Director, Local HealthDistrict Chief Executive

or Delegate, and Ministry of Health use Reportable Incident Brief

Note that the Senior Manager is responsible for coordinating

the service response and ensuring follow-up is provided.

A review should take place via Root Cause Analysis/Sentinel

Events Review or Reportable Incident Brief (RIB) structures.

If the alleged perpetrator is a staff member

■ In addition to the steps outlined above, if the alleged

perpetrator is a NSW Health staff member:

– A Reportable incident Brief (RIB) must be submitted

within 24 hours to the Ministry of Health for sexual

misconduct and for sexual assault allegations made

against staff members.

■ A decision must be made about whether the staff

member’s name must be entered onto the NSW

Health Service Check Register in accordance with the

NSW Health Service Check register policy.

■ The NSW Police must be informed of any criminal

allegations against NSW Health staff members.

■ The NSW Ombudsman must be notified of any

allegations relating to sexual offences or sexual

misconduct by NSW Health staff members where the

alleged victim was under 18 years of age at the time

of alleged conduct.

External

External reporting is required under the following

circumstances:

If the consumer who has disclosed the sexual assault

indicates that the perpetrator is a staff member

■ To support transparency, all allegations of sexual

assault of a consumer by a staff member must be

reported to the NSW Police Force.

■ The consumer will need to be advised of this and the

rationale for taking this step so that they are not

made to feel disempowered if this action is not in line

with their wishes. However, there is no obligation for

the consumer to lodge a formal complaint with Police

against the staff member if they do not wish to do so.


is under 18 years of age

■ Any staff member that has a concern about any risk

of significant harm to a child or young person needs

to report their concern to the Child Protection

Helpline (13 36 27). This risk of significant harm may

include: any sexual intercourse involving a child under

the age of 16 years; sexual assault, abuse or neglect

of a child or young person; or any child or young

person or class of children or young people who may

be in contact with an alleged perpetrator.

■ The summary below notes the steps to be taken

when reporting:


about their capacity to make an informed decision

(see Assessing capacity to make informed decisions

for further advice).

■ Information should be provided to the consumer

regarding reporting to Police to help them to decide

whether or not this is how they want to proceed, and

whether they wish to make a formal complaint or

simply notify the Police that the incident has occurred.

Appendix E provides relevant information for this

purpose. ■ In all circumstances, the wishes of the consumer in

relation to making a Police report must be respected,

unless the consumer indicates that the perpetrator is

a staff member. In this circumstance, Police must be

notified of the alleged incident to ensure transparency

regardless of whether the consumer wishes to take

this step, but a formal complaint does not have to

be made by the consumer if they do not wish to

make one.


requests support from the local Sexual Assault Service

■ All requests by the consumer to report the assault to

the local Sexual Assault Service should be actioned.

■ Information should be provided to the consumer

regarding how the Sexual Assault Service can help them,

including reporting to Police to help them to decide

whether or not this is how they want to proceed.

■ The local Sexual Assault Service can also provide

information regarding legal and complaint options

and help the consumer to explore these in relation

to their own needs and circumstances and to move

towards a decision that is best for them. Involvement

of or consultation with the Sexual Assault Service is

important as legislation and witness support

þComplete the Mandatory Reporter Guide (MRG) tool to help you identify if there is risk of significant harm.

You can access the MRG at http://www.keepthemsafe.nsw.gov.au/home. Hard copies of the MRG are also available

at health workplaces.

þIf you identify risk of significant harm, call the Child Protection Helpline on 13 36 27 (for mandatory reporters) or

in an emergency, call 000.

þHealth Child Wellbeing Units (CWU) provide advice to NSW Health workers on what action to take and who to

talk to about concerns for children at risk.

þContact child protection professionals at the CWU on 1300 480 420:

– if you are uncertain about what action to take

– if you need help on how to use the Mandatory Reporter Guide (MRG)

– to inform the CWU of concerns for a child or young person below the threshold for risk of significant harm

– where the Mandatory Reporter Guide advises you to do so.

■ If the report concerns a young person aged over 16

but under 18 years, the young person should be

involved in the decision to report to the Child

Protection Helpline and the process of reporting,

unless there are exceptional reasons for excluding

them. Staff should note that a young person may

perceive sexual activity as consensual because of the

way the other person involved has promoted it, even

though the situation may be one of sexual abuse and

exploitation. If the young person does not agree to

the report being made, staff may still make a report

and this information must be conveyed to Community

Services, as they must consider the young person’s

wishes in any investigations and assessments.

■ All concerns that a child or young person may be at

risk of significant harm and action taken are to be

documented in the consumer’s health record.

■ For any allegations of sexual assault by a NSW Health

staff member against a person who was under 18

years of age at the time of the alleged assault (even if

they are an adult now), the NSW Police must be notified.

■ The NSW Ombudsman must also be notified of any

allegations of sexual assault or sexual misconduct

against current staff members where the alleged victim

is under 18 years of age at the time of the alleged

assault, regardless of where or when the alleged assault

is said to have occurred, and the health service must

complete an investigation in accordance with the NSW

Ombudsman’s requirements, and notify the Commission

for Children and Young People as required.


requests that the assault is reported to the Police

■ All requests by the consumer to report the assault to

the Police should be actioned, unless there is doubt

http://www.keepthemsafe.nsw.gov.au/home


provisions may change; it is the role of the Sexual

Assault Service to maintain up to date knowledge.


requests support from the service to notify their family

or carer

■ The service can help the consumer talk to their family

or carer about the assault, if they request this.

■ However, consent is required for staff to take this

action, regardless of whether the consumer is

voluntary or involuntary, and must be clearly

documented in the consumer’s file.

■ The Sexual Assault Service can also provide counselling

to family and significant others – this may be a counsellor

separate to the counsellor who sees the consumer if

indicated. This intervention is concerned with ensuring

that family is able to appropriately respond to the

consumer and to provide trauma informed support.

6.1.2 Recording The sexual assault incident needs to be clearly and

accurately recorded in the file of the consumer who has

disclosed the sexual assault and the alleged perpetrator’s

file. Documentation should comprise actual accounts of

events using the consumer’s own words and clear

descriptions of behaviours wherever possible.

Terminology or language which can be interpreted in

different ways should not be used (e.g. terms such as

‘inappropriate’ or ‘suspicious’).

File of the consumer who has disclosed the sexual assault

The consumer’s file should record:

■ Specific details including the nature, time and location

of the allegation, any witnesses, the consumer’s account.

■ The consumer’s clinical state including mental status,

the effects of the assault, and any coping strategies

used.

■ That the consumer has been provided with

information regarding their rights, action which may

be taken and support available.

■ Any management strategies implemented and their

outcome (i.e. helpful or not).

■ To whom the incident has been reported, the actions

taken thus far and the wishes of the consumer in

relation to reporting the incident to external agencies,

such as Police or the local Sexual Assault Service.

■ The Incident Information Management System (IIMS)

notification number.

■ A review of the consumer’s current status using the

MH-OAT Standard Measure 1B (SM1B) needs to be

completed. (MH-OAT protocols require the

completion of a SM1B in response to a critical

incident.)

■ Where the allegation relates to a NSW Health staff

member, the consumer’s file should not contain all

the details but should provide a reference to the

location of the information.

Subpoenaed Files

■ Medical records staff need to be provided with clear

information about the information to be provided if a

consumer’s file is subpoenaed for legal proceedings in

response to a sexual assault investigation. In particular,

Sexual Assault Communications Privilege must be

considered. (People who have experienced a sexual

assault have certain protection against discussions

with counsellors being obtained under subpoena by

Defendants in criminal proceedings. The aim is to

protect the confidentiality of sexual assault counselling,

so as to encourage people who have experienced

sexual assault to seek counselling, and to make them

feel more confident about actually reporting sexual

assaults – see Subpoenas PD2010_065)

■ Further, if the consumer’s file is subpoenaed for some

other reason, it should be noted that the consumer’s

file contains information of a sensitive nature that must

not be provided except where the legal proceedings

are relevant to the specific sexual assault and Sexual

Assault Communications Privilege does not apply.

■ Under Section 29 of the Children and Young Persons

(Care and Protection) Act 1998 the protection of the

reporter’s identity must be considered by services

when executing exchange of information requests,

providing a response to court subpoena or responding

to requests for public access to government information.

■ Section 29 protects the identity of people who report

concerns about children and young people to the

Child Protection Helpline or to a Child Wellbeing Unit

which sends the report on to the Child Protection

Helpline. It also protects the identity of persons

concerned in making the report or causing the report to

be made. It is prohibited under this section to disclose

the reporter’s identity as well as any information from

which the reporter’s identity might be deduced.


■ A local protocol for Medical Records staff must be

developed to ensure there is a clear process for

identifying issues associated with the use of medical

files as evidence in legal proceedings.

File of the person who has been identified as the perpetrator of the sexual assault

Where the alleged perpetrator is a consumer, the

following information is to be recorded in their file:

■ Specific details including the time and location of the

incident and any witnesses.

■ Whether the alleged perpetrator has been informed

of the allegation of sexual assault. (The alleged

perpetrator should not be informed of the allegation

immediately where this may compromise the

investigation or the safety of the consumer who has

experienced the sexual assault.)

■ That the alleged perpetrator has been provided

information regarding their legal rights including

access to legal services.

■ To whom the incident has been reported and actions

taken thus far. This includes any medical response,

who has been notified, Police involvement and what

consent has been given.

■ IIMS notification number.

Where the alleged perpetrator is a staff member, the

following information is to be recorded by the Senior

Manager and kept separately from the staff member’s

HR file:

■ Specific details including the nature, time and location

of the alleged incident and any witnesses, and when

and how reported.

■ Details of any action taken in response to the

allegation, such as counselling to any of the parties,

notifications to external bodies such as he NSW

Police, Child Protection Helpline etc.

■ Any advice or information from NSW Police or

Community Services, including advice that the NSW

Health investigation may commence.

■ Details of any investigation, including any

investigation plan, details of interviews with relevant

parties, details of any risk assessments and related risk

management decision, including decisions around the

NSW Health Service Check Register.

■ The investigation report and all other documentation

created in relation to the investigation.

■ Any submissions from the staff member.

■ Signed and dated File Notes must be kept of each

telephone conversation, interview, notification sent

and advice received during an internal investigation

■ All e-mail correspondence.

■ IIMS notification number.


6.2.1 Reporting Internal

When consensual sexual activity in an inappropriate

context or setting has been disclosed or reported, the

incident must be reported as follows:


The Team Leader/Nursing Unit Manager

External

External reporting of this type of sexual safety incident is

not required.

6.2.2 RecordingIf the consumers involved in this type of sexual safety

incident are both in an inpatient or residential setting,

files for both consumers must have the incident

documented in their files. Any action taken must be

documented as well, including any increase in levels of

observation, assessment of the consensual, voluntary and

mutual nature of the sexual activity, counselling or

education for consumer/s involved or debriefing with

consumers who may have witnessed the incident.



6.3.1 Reporting Internal

When sexually disinhibited behaviour has been disclosed

or reported, the incident must be reported as follows:


The Team Leader/Nursing Unit Manager

External

External reporting of this type of sexual safety incident is

not required.

6.3.2 RecordingThe consumer’s behaviour must be noted in their file due

to their own and other consumer’s vulnerability, and

because of the need for an increase in levels of

observation to enhance safety and minimise the risk of

the occurrence of further disinhibited behaviour.

A plan to manage any future incidents should be

developed and any actions taken must be documented

including an increase in level of observation, debriefing

with consumers around the incident and advice to the

consumer, and their family and carer, about strategies

noted within the management plan so that a consistent

message is provided.


7.1 Consumers who are Aboriginal and Torres Strait Islander

The prevalence of trauma such as sexual assault within

the Aboriginal and Torres Strait Islander communities

across Australia is relatively high. Yet non-Aboriginal staff

often feel challenged and uncertain about the most

culturally respectful and competent approach to

effectively supporting Aboriginal consumers who have

experienced sexual assault and violence.

Although it relates specifically to family violence in

Aboriginal communities, the Aboriginal Family Health

Strategy (http://www.health.nsw.gov.au/pubs/2011/

aboriginal_family_health_.html )provides an example of

the approach and specific considerations that would

enhance service provision to Aboriginal consumers in

relation to sexual safety. In particular, the Principles of

Aboriginal Health, the Model of Care and the healing

approach promoted by the Strategy, should be considered

where appropriate.

One of the key tactics highlighted within the Strategy is

the provision of clear, effective and culturally appropriate

information for Aboriginal people. Mental health staff

should consider sourcing culturally appropriate and

sensitive material that supports advice to the consumer

and family about responding to sexual assault and

violence. Alternatively, services may wish to develop their

own resources for the specific Aboriginal communities in

their locality. The following NSW Health resources may

provide advice and support in relation to this.

Communicating Positively

http://www.health.nsw.gov.au/pubs/2004/aboriginal_

terms.html

Working with Aboriginal Communities

http://www.community.nsw.gov.au/docswr/_assets/

main/documents/working_with_aboriginal.pdf

Relevant training for mental health staff will also be

critical to enhancing cultural competence in responding

to sexual safety incidents involving Aboriginal mental

health consumers. The Education Centre Against Violence

(ECAV) provides a number of relevant courses including:

Defining healthy boundaries when working in

Aboriginal communities

(http://www.ecav.health.nsw.gov.au/ecav/index.

asp?pg=2&s=C&cNo=175)

This training is for Aboriginal staff who engage in

supportive and healing relationships with Aboriginal

clients and communities that have experienced family

violence, child abuse, adult or child sexual assault.

NSW Health specialist Sexual Assault Services training

http://www.ecav.health.nsw.gov.au/ecav/index.

asp?pg=2&s=C&cNo=200

Defines culturally competent responses to diverse

population groups including Aboriginal or Torres

Strait Island people and people of Culturally and

Linguistically Diverse backgrounds.

Where possible, appropriately qualified Aboriginal

Workers or Aboriginal Liaison Officers (within agencies

e.g. hospitals, Police) should be engaged to work with

consumers around appropriately preventing and

responding to sexual safety incidents.

It is also vital that the Aboriginal status of clients is

recorded accurately and consistently in order to develop

and improve, monitor and evaluate services providing

care and protection for Aboriginal children and families.

In general, Aboriginal status is poorly recorded in health

related data and consequently the utilisation of services

by Aboriginal clients is under represented. This in turn

contributes to insufficient culturally appropriate and

accessible service provision. See principles for recording

Aboriginal and Torres Strait Islander origin information of

consumers and clients

http://www.health.nsw.gov.au/policies/

pd/2012PD2012_042.html.

SECTION 7

Highly vulnerable groups

http://www.health.nsw.gov.au/pubs/2011/aboriginal_family_health_.html

http://www.health.nsw.gov.au/pubs/2011/aboriginal_family_health_.html

http://www.health.nsw.gov.au/pubs/2004/aboriginal_terms.html

http://www.health.nsw.gov.au/pubs/2004/aboriginal_terms.html

http://www.community.nsw.gov.au/docswr/_assets/main/documents/working_with_aboriginal.pdf

http://www.community.nsw.gov.au/docswr/_assets/main/documents/working_with_aboriginal.pdf

http://www.ecav.health.nsw.gov.au/ecav/index.asp?pg=2&s=C&cNo=175




http://www.health.nsw.gov.au/policies/pd/2005/PD2005_547.html



7.2 Consumers who are children or young people

The Children and Young Persons (Care and Protection)

Act 1998 defines a child as ‘a person under the age of

under 16 years’ and a young person as ‘a person who is

aged 16 years or above but who is under the age of 18

years’ (i.e. a person who is 16 or 17 years old). In addition,

the minimum age of consent for sexual activity in NSW is

16 years old. The NSW Ombudsman defines children as

being under the age of 18 years of age when dealing

with allegations of sexual assault by staff members.

While children and young people may be vulnerable to

sexual assault, they may also pose risks to other consumers,

especially when exploring their sexuality and experimenting

with sexual behaviour. Children and young people can

display a continuum of sexual behaviour, where at one

end they display healthy, age-appropriate sexual

behaviour and at the other may in some circumstances

engage in behaviours that are problematic or abusive.

Accordingly, mental health staff should not assume that

an age-specific service is automatically safe. Appropriate

risk assessment and mitigation will need to be

undertaken in all service settings that cater to the needs

of children and young people, including inpatient,

rehabilitation and community-based services.

Communication is also a key factor in the sexual safety of

consumers who are children and young people. Children

and young people may be reluctant to communicate their

experiences verbally, meaning mental health staff will need

to adopt communication styles that allow the child or

young person to feel safe to communicate in their own way.

Education about contraception and other aspects of

sexual health and safety may support young consumers

to better communicate about any sexual safety issue, and

consideration of the educative needs of this group should

be a routine part of comprehensive individually-tailored

care planning and service delivery.

Family and carers, who play an integral role in the

provision of care for this age group, can support children

and young people to understand the sexual safety

standards in place for the service and to speak up about

any incidents of sexual assault or harassment they are

subjected to or witness. However, staff must be cognisant

that the involvement of families and carers is subject to

child protection requirements where these are an issue.

Mental health staff must also be aware that if they

suspect, on reasonable grounds, that a child or young

person is at ‘risk of significant harm’ from abuse or

neglect, they must report these concerns to the

Community Services’ Child Protection Helpline. NSW

Ministry of Health Information Bulletin Keep Them Safe –

Making a Child Protection Report IB2010_005 (http://

www.health.nsw.gov.au/policies/ib/2010/IB2010_005.

html ) defines ‘significant harm’ as follows:

What is meant by ‘significant’ is that which is

sufficiently serious to warrant a response by a

statutory authority irrespective of a family’s consent.

What is significant is not minor or trivial and may

reasonably be expected to produce a substantial and

demonstrably adverse impact on the child or young

person’s safety, welfare or wellbeing.

Keep Them Safe – Making a Child Protection Report

IB2010_005 (http://www.health.nsw.gov.au/policies/

ib/2010/IB2010_005.html) outlines the legislative

requirements of NSW Health staff in protecting and

supporting the safety, welfare and wellbeing of children

and young people and reinforces the principle that care

and protection of children and young people is a shared

responsibility.

The NSW Mandatory Reporter Guide (MRG) assists NSW

Health staff in deciding whether concerns for the safety,

welfare and wellbeing of children and young people meet

the risk of significant harm threshold (NSW Mandatory

Reporter Guide - http://sdm.community.nsw.gov.au/mrg/

app/summary.page).

NSW Health Child Wellbeing Units (CWU) provide advice

to NSW Health staff on what action to take and who to

talk to about concerns for children at risk.

Mental health staff should contact child protection

professionals at the CWU on 1300 480 420:

■ if they are uncertain about what action to take

■ if they need help on how to use the Mandatory

Reporter Guide (MRG)

http://www.health.nsw.gov.au/policies/ib/2010/IB2010_005.html





■ to inform the CWU of concerns for a child or young

person below the threshold for risk of significant

harm

■ where the Mandatory Reporter Guide advises to do so.

Mental health staff should also familiarise themselves

with the following contact information:

■ Community Services’ Child Protection Helpline for

mandatory reporters – 13 36 27

■ NSW Health Child Wellbeing Units – 1300 480 420

■ NSW Health Keep Them Safe Website

http://www.health.nsw.gov.au/initiatives/kts/index.asp

■ Department of Premier and Cabinet Keep Them Safe

Website


■ NSW Ombudsman Child Protection in the workplace –

responding to allegations against employees –

http://www.ombo.nsw.gov.au/news-and-publications/

publications/guidelines/child-protection

7.3 Consumers from a culturally and linguistically diverse background

Mental health consumers from culturally and linguistically

diverse (CALD) backgrounds who are sexually assaulted or

harassed can face multiple layers of disadvantage due to

a range of factors such as racism, the fear of bringing ‘shame’

to their family, and disconnection from their community.

Being able to effectively communicate about sexual safety

issues is the first step in ensuring that the special needs

of CALD consumers are taken into account. The NSW

Health Care Interpreter Service can assist persons from

CALD backgrounds who present with communication

difficulties – refer to NSW Ministry of Health Policy

Directive Standard Procedures for Working with Health

Care Interpreters PD2006_053. (http://www.health.nsw.

gov.au/policies/pd/2006/PD2006_053.html)

Should the NSW Heath Care Interpreter Service not be

able to assist in the provision of a language resource, the

Translating & Interpreting Service (http://www.immi.gov.

au/living-in-australia/help-with-english/help_with_

translating/ ) may be called upon for assistance.

While the Transcultural Mental Health Centre is not an

interpreting service, they may be engaged when specialist

cross cultural assessment or consultation is required.

The Centre also provides limited clinical care and

management and these services can be accessed through

Local Health Districts.

Family members, carers and friends may volunteer to

assist with interpreting during the reporting of an

incident, and this is acceptable at the first point of

contact and may be beneficial in establishing any

immediate concerns.

However family and friends of the consumer who has

experienced an assault are inappropriate substitutes for a

professional interpreter in the long term and their interests

may actually be different from or in conflict with those of

the consumer. Accordingly, an interpreter service should

be engaged as soon as practicable, and this advice should

be provided to the consumer’s family.

Culturally and linguistically appropriate information

regarding sexual violence and victims’ rights and services

are also critical. Services will need to consider the literacy

level of the consumer though and be prepared to explain

the written information in a clear and concise way,

highlighting relevant contact details and what support

can be accessed.

Documents that may provide further support for mental

health staff include:

■ Multicultural Mental Health Plan 2008-2012 –

PD2008_067 (http://www.health.nsw.gov.au/policies/

pd/2008/pdf/PD2008_067.pdf)

■ NSW Refugee Health Plan 2011-2016 – PD2011_014

(http://www.health.nsw.gov.au/policies/pd/2011/

PD2011_014.html)

7.4 Consumers with Intellectual Disability

People with intellectual disability (ID) often have key

deficits in adaptive behaviour such as social problem

solving and social judgement that can contribute to the

risk of sexual abuse or assault. When a person with ID

also has a mental illness or disorder, this risk can be

substantially increased. Social dislocation, fragmented

care and lack of education about sexuality and sexually

appropriate behaviour may also contribute to this

vulnerability.

Basic sex education, tailored to individually suit the


http://www.ombo.nsw.gov.au/news-and-publications/publications/guidelines/child-protection

http://www.ombo.nsw.gov.au/news-and-publications/publications/guidelines/child-protection



http://www.immi.gov.au/living-in-australia/help-with-english/help_with_translating/

http://www.health.nsw.gov.au/policies/pd/2008/pdf/PD2008_067.pdf

http://www.health.nsw.gov.au/policies/pd/2008/pdf/PD2008_067.pdf



communication and comprehension level of the consumer

with ID, can help to combat this vulnerability by providing

the consumer with the knowledge to understand the

difference between normal sexual activity and sexual

assault. Armed with this knowledge, consumers with ID

can more effectively identify when they are being

victimised and develop self-protective behaviours.

Consumers with ID will also benefit from being provided

with clear advice about their rights in relation to sexual

safety, such as their right to say ‘no’ to sexual activity.

As people with ID can lack the confidence to assert their

rights even when they are aware of them, education will

also be required to help consumers with ID learn how to

ensure these rights are upheld. This in turn will support

them to speak up should they experience a sexual safety

incident.

While many adults with mild ID engage in fulfilling

consensual sexual relationships, some people with ID will

lack the capacity to make decisions in relation to this area

of their life.

Consumers with ID will benefit from an assessment of

their communication skills and current level of knowledge

and understanding regarding sexual and personal

relationships – see Section 5.2.1 Understanding consent

and capacity – to ensure they have the capacity to consent

to sexual activity. Further information regarding what the

law in NSW says about consent is provided at Appendix C.

The capacity of consumers with ID to make decisions if

they have been assaulted will also need to be considered

– further information regarding this is provided under the

heading Assessing capacity to make informed decisions,

page 41.

7.5 Gay, Bisexual, Lesbian and Transgender Consumers

The underlying issue in managing sexual safety for Gay,

Bisexual, Lesbian and Transgender (GLBT) mental health

consumers is the impact of real or perceived homophobia

and transphobia.

Homophobia is a term used to describe a range of

negative attitudes and feelings towards homosexuality

and people who are identified or perceived as being gay,

lesbian or bisexual.

Homophobia can occur in obvious and subtle ways and

can include:

■ Cultural stereotypes about acceptable forms of

conduct around GLB people that degrades their

sexual orientation;

■ Condoning homophobia by not addressing

inappropriate language/behaviour by others;

■ Discounting the severity and impact of a sexual

assault/harassment incident between people of the

same-sex, where a GLB person is involved, due to a

misconception that the behaviour is less traumatic

because of the gender of the perpetrator.

The impact of homophobic behaviours on GLB individuals

can be devastating, reducing their sense of personal

safety or increasing vulnerability to sexual incidents. For

GLB people who have experienced unwanted sexual

behaviours, fear or perceptions of homophobia may

affect their willingness to disclose the incident, due to

fears of receiving a lesser standard of support.

Transphobia refers to discrimination against transsexuality

and transsexual or transgender people because they do

not conform to or who transgress societal gender

expectations and norms.

While many of the ways in which homophobia manifests

itself can also impact on transgender consumers, there

are additional issues to consider in relation to the sexual

safety of this group, such as:

■ The assumption that gender identity is a disorder and

the individual’s presenting issue.

■ A misconception that gender identity and sexual

orientation are the same. Gender identity and sexual

orientation are two distinct issues. Transgender

people can be heterosexual, gay, lesbian or bisexual.

■ An inability to accept a transgender person’s chosen

gender. This can impact on transgender women’s

access to single sex spaces, thus increasing

vulnerability; and increase the vulnerability of

transgender men in male single sex settings.

Creating a culture of acceptance that normalises diverse

sexual orientations and gender identities will assist in

promoting sexual safety as well as encouraging openness

in reporting sexual safety incidents. Mental health

services can create safe and non-judgemental

environments for GLBT consumers through actively

http://en.wikipedia.org/wiki/Attitude_(psychology)

http://en.wikipedia.org/wiki/Homosexuality


promoting the service’s acceptance of diverse sexual

orientations and gender identities, and having a clear

protocol or policy in place that dictates the

unacceptability of homophobic and transphobic

behaviour from either providers or consumers.

7.6 Older consumers

While the ageing process may impact on their sexual

health, older people continue to see sexual relationships

as an important aspect of their life.

However, older people are often viewed by society as

being physically unattractive, uninterested in sex and

incapable of achieving sexual arousal. Mental health staff

caring for older consumers need to challenge these

societal attitudes within their service to avoid the

inadvertent nurturing of professional responses and an

environment that could:

■ Discourage older mental health consumers from

reporting or freely discussing sexual safety incidents

■ Lead to an inappropriate categorisation and

intervention of sexual activity / expression from an

older mental health consumer; and

■ Overlook the needs of older mental health consumers

that are particularly vulnerable to sexual safety

incidences, including people that are cognitively

impaired, physically frail and/or with severe

depression.

The sexual safety of older mental health consumers can

also be impacted upon by dementia, which can be

complicated by behavioural and psychological symptoms

of dementia (BPSD). BPSD is an umbrella term for a

diverse group of non-cognitive symptoms such as

psychosis, depression, agitation, inappropriate sexual

behaviour, restlessness, intrusiveness and resistance

to care.

In aged residential care settings, it is common for older

mental health consumers with a diagnosis of BPSD, and

to a lesser extent with other diagnosis such as mania, to

be referred to Specialist Mental Health Services for Older

People (SMHSOP) when there has been a sexual safety

incident. These sexual safety incidents generally relate to

sexual activity such as masturbation in an inappropriate

setting, sexually disinhibited behaviour such as disrobing

and inappropriately touching nursing staff that are

providing care, and staff perceptions of older mental

health consumers and sexual safety.

Managing these referrals in an environment with other

older mental health consumers who are particularly

vulnerable to sexual safety requires specialised

intervention and an interagency approach.


Appendices

APPENDIX A Example Standards of Behaviour for an Acute Inpatient Mental Health Service setting and a Non-acute Inpatient or Rehabilitation Mental Health Service setting

APPENDIX B Charter of Victims Rights

APPENDIX C Relevant standards and legislation

APPENDIX D Information about support options for consumers who have experienced sexual assault

APPENDIX E Information about reporting to Police for consumers who have experienced sexual assault

APPENDIX F Example posters to promote Sexual Assault Services

APPENDIX G Sexual Assault Screening Tool

APPENDIX H Examples of sexualised behaviour by healthcare professionals towards consumers or their carers

APPENDIX I Responding to a disclosure of sexual assault – key actions

APPENDIX J Responding to a disclosure of recent sexual assault – quick checklist

APPENDIX K Follow up medical exams required when a person has been sexually assaulted

APPENDIX L Reporting process for an incident of sexual assault

APPENDIX M Information about managing Disinhibited Behaviour


APPENDIX A

Example Sexual Safety Standards of Behaviour

Sexual Safety Standards of Behaviour for an Acute Inpatient Mental Health ServiceAll consumers involved with this mental health service are asked to adhere to the following standards of behaviour in

relation to sexual safety.

Standard 1 I respect myself.

Standard 2 I treat others with respect, dignity and courtesy.

Standard 3 I do not engage in any sexual activity with another person while on the grounds of the service.

Standard 4 I do not try to talk someone else into engaging in sexual activity, or harass another person sexually.

Standard 5 I try to be aware of how my behaviour makes others feel, and will change my behaviour if someone tells me it makes them uncomfortable, or I will ask for help with this if I need to.

Standard 6 I respect the rights of others to space and privacy to fulfil their sexual needs through masturbation.

Standard 7 I understand that fulfilling my own sexual needs through masturbation must be conducted privately and discreetly.

Standard 8 I speak up if I have been hurt, harassed or assaulted either physically or sexually.

Standard 9 I speak up if I see or hear about someone else being hurt, harassed or assaulted either physically or sexually.

Example Sexual Safety Standards of Behaviour for a Non-Acute Inpatient or Rehabilitation Mental Health ServiceAll consumers involved with this mental health service are asked to adhere to the following standards of behaviour in

relation to sexual safety.

Standard 1 I respect myself.

Standard 2 I treat others with respect, dignity and courtesy.

Standard 3 I only engage in sexual activity with another person when they have given their consent.

Standard 4 I do not try to talk someone else into engaging in sexual activity, or harass another person sexually.

Standard 5 I only engage in sexual activity with another person in the privacy of my own or the other person’s room, or a room that is provided by the service, while on the grounds of the service.

Standard 6 I understand that sexual activity with another person should be for mutual pleasure, and never used for punishment.

Standard 7 I never intentionally hurt anyone when engaging in sexual activity with them, and I understand that I must stop engaging in sexual activity when the person I am with says ‘stop’.

Standard 8 I always practice safe sex and use a condom when engaging in sexual activity with another person.

Standard 9 I try to be aware of how our behaviour makes others feel, and will change my behaviour if someone tells me it makes them uncomfortable, or I will ask for help with this if I need to.

Standard 10 I respect the rights of others to space and privacy to fulfil their sexual needs through masturbation.

Standard 11 I understand that fulfilling my own sexual needs through masturbation must be conducted privately and discreetly.

Standard 12 I speak up if I have been hurt, harassed or assaulted either physically or sexually.

Standard 13 I speak up if I see or hear about someone else being hurt, harassed or assaulted either physically or sexually

.


APPENDIX B

Charter of Victims Rights

Extract from the Victims Rights Act 1996 – Part 2, Section 6Courtesy, compassion and respect

A victim should be treated with courtesy, compassion, and respect for the victim’s rights and dignity.

Information about services and remedies

A victim should be informed at the earliest practical opportunity, by relevant agencies and officials, of the services and remedies available to the victim.

Access to services

A victim should have access where necessary to available welfare, health, counselling and legal assistance responsive to the victim’s needs.

Information about investigation of the crime

A victim should, on request, be informed of the progress of the investigation of the crime, unless the disclosure might jeopardise the investigation. In that case, the victim should be informed accordingly.

Information about prosecution of accused

A victim should, on request, be informed of the following:

(a) the charges laid against the accused or the reasons for not laying charges,

(b) any decision of the prosecution to modify or not to proceed with charges laid against the accused, including any decision for the accused to accept a plea of guilty to a less serious charge in return for a full discharge with respect to the other charges,

(c) the date and place of hearing of any charge laid against the accused,

(d) the outcome of the criminal proceedings against the accused (including proceedings on appeal) and the sentence (if any) imposed.

Information about trial process and role as witness

A victim who is a witness in the trial for the crime should be informed about the trial process and the role of the victim as a witness in the prosecution of the accused.

Protection from contact with accused

A victim should be protected from unnecessary contact with the accused and defence witnesses during the course of court proceedings.

Protection of identity of victim

A victim’s residential address and telephone number should not be disclosed unless a court otherwise directs.

Attendance at preliminary hearings

A victim should be relieved from appearing at preliminary hearings or committal hearings unless the court otherwise directs.

Return of property of victim held by State

If any property of a victim is held by the State for the purpose of investigation or evidence, the inconvenience to the victim should be minimised and the property returned promptly.

Protection from accused

A victim’s need or perceived need for protection should be put before a bail authority by the prosecutor in any bail application by the accused.

Information about special bail conditions

A victim should be informed about any special bail conditions imposed on the accused that are designed to protect the victim or the victim’s family.

Information about outcome of bail application

A victim should be informed of the outcome of a bail application if the accused has been charged with sexual assault or other serious personal violence.


Victim impact statement

A relevant victim should have access to information and assistance for the preparation of any victim impact statement authorised by law to ensure that the full effect of the crime on the victim is placed before the court.

Information about impending release, escape or eligibility for absence from custody

A victim should, on request, be kept informed of the offender’s impending release or escape from custody, or of any change in security classification that results in the offender being eligible for unescorted absence from custody.

Submissions on parole and eligibility for absence from custody of serious offenders

A victim should, on request, be provided with the opportunity to make submissions concerning the granting of parole to a serious offender or any change in security classification that would result in a serious offender being eligible for unescorted absence from custody.

Compensation for victims of personal violence

A victim of a crime involving sexual or other serious personal violence should be entitled to make a claim under a statutory scheme for victims’ compensation.


APPENDIX C

Relevant standards and the legislative framework

Relevant standards

■ UN Declaration – Rights of Disabled Persons

http://www.un-documents.net/a30r3447.htm

■ UN Principles for the Protection of Persons with

Mental Illness and for the Improvement of Mental

Health Care

www.un.org/documents/ga/res/46/a46r119.htm

■ NSW Ministry of Health Charter for Mental Health

Care in NSW

www.health.nsw.gov.au/pubs/2000/mhcharter.html

■ National Statement of Rights and Responsibilities of

Consumers of Mental Health Services

http://www.health.gov.au/internetmhsc/publishing.

nsf/Content/pub-sqps-rights

The legislative framework

Medical Practice Act 1992

■ Section 71A of the Medical Practice Act introduces

‘reportable misconduct’, placing an obligation on

doctors to report certain types of misconduct to the

Medical Board. This requirement came into force on

1 October 2008.

■ The reporting obligations are not general, but focus

on three areas of serious misconduct, one of which is

sexual misconduct.

■ The misconduct to be reported is linked to the

practice of medicine. Under current Board policy,

it is an absolute rule that a medical practitioner who

engages in sexual activity with a current patient/

consumer is guilty of professional misconduct.

■ Engaging in sexual activity with a patient/consumer

following the termination of the doctor/patient

relationship may also amount to professional

misconduct, depending on the circumstances of each

case. For more information refer to the Board’s policy

on sexual misconduct.

www.mcnsw.org.au/resources/1034

Crimes Act 1900

http://www.legislation.nsw.gov.au/fullhtml/inforce/

act+40+1900+cd+0+N

■ The Crimes Act 1900 consolidates the Statutes

relating to Criminal Law and regulates criminal law in

NSW.

■ Part 3 Division 10 relates to sexual assault offences.

■ Section 66F refers specifically to people with a

‘cognitive impairment’, which is defined in the act

as follows:

…a person has a cognitive impairment if the

person has:

(a) an intellectual disability, or

(b) a developmental disorder (including an autistic

spectrum disorder), or

(c) a neurological disorder, or

(d) dementia, or

(e) a severe mental illness, or

(f) a brain injury,

that results in the person requiring supervision or

social habilitation in connection with daily life

activities. Section 61H, (1A)

■ Under Section 66F (2) the Act states that a person

who has sexual intercourse with a person who has a

cognitive impairment and who was responsible for

the care of that person, whether generally or at the

time of the sexual intercourse, is guilty of an offence.

The maximum penalty for this offence is

imprisonment for 10 years.

http://www.un-documents.net/a30r3447.htm

http://www.health.gov.au/internet/main/Publishing.nsf/Content/mental-pubs-m-rights-toc

http://www.legislation.nsw.gov.au/fullhtml/inforce/act+40+1900+cd+0+N

http://www.legislation.nsw.gov.au/fullhtml/inforce/act+40+1900+cd+0+N


■ The Act defines a ‘person responsible for care’ as

follows:

… a person is responsible for the care of a person

who has a cognitive impairment if the person

provides care to that person:

(a) at a facility at which persons with a cognitive

impairment are detained, reside or attend, or

(b) at the home of that person in the course of a

program under which any such facility or other

government or community organisation provides

care to persons with a cognitive impairment.

The care of a person with a cognitive impairment includes

voluntary care, health professional care, education, home

care and supervision.

Section 66F, (1)

■ Under Section 66F (3) a person who has sexual

intercourse with a person who has a cognitive

impairment, with the intention of taking advantage of

that person’s cognitive impairment, is guilty of an

offence. The maximum penalty for this offence is

imprisonment for eight years. Attempting sexual

intercourse attracts the same penalties.

■ Importantly, under Section 66F (5) consent is not a

defence for sexual intercourse on the basis that in

many of these cases it would be considered that the

victim is incapable of giving informed consent.

Victims Rights Act 1996

http://www.legislation.nsw.gov.au/sessionalview/

sessional/act/1996-114.pdf

■ The purpose of this Act is to recognise and promote

the rights of victims of crime. It establishes a Charter

of Victim’s Rights for the appropriate treatment of

victims of crime by government agencies and those

funded by government. This includes Police, health,

welfare, prosecution and correctional services.

■ This means that mental health staff have an

obligation to take account of the Charter in the

administration of their service when dealing with

a victim of crime.

■ The Charter is monitored by the Victim Services,

Department of Attorney General and Justice’ (http://

www.lawlink.nsw.gov.au/vs).

■ The rights outlined within the Charter have been

included at Appendix A.

Health Records and Information Privacy Act

www.legislation.nsw.gov.au/fullhtml/inforce/

act+71+2002+FIRST+O+N

■ The purpose of this Act is to promote fair and

responsible handling of health information by both

the private and public health sector.

■ Schedule 1 of this Act provides a set of Principles that

pertain specifically to public health organisations.

Health Privacy Principles (http://www.austlii.edu.au/

au/legis/nsw/consol_act/hraipa2002370/sch1.html)

Children and Young Persons (Care and Protection) Act 1998

http://www.legislation.nsw.gov.au/fullhtml/inforce/

act+157+1998+FIRST+0+N

■ Health care staff, including mental health, are

considered under this Act to be mandatory reporters.

■ A mandatory reporter is someone who is required

by law to make a report to the Department of

Community Services (DoCS) if they have current

concerns about the safety, welfare or wellbeing of a

child. This includes concerns about the child or young

person having been sexually abused or being at risk

of being abused. Mandatory reporters face penalties

for failing to make a report.

■ A child is a person under 16 years of age and a young

person is 16 or 17 years old. This is an important

distinction because the Act has different provisions

for children and young people.

■ Mandatory reporting requirements only apply to

children. Services can also report concerns they may

have about the safety, welfare or well-being of a

young person, but this is not a mandatory reporting

requirement (Refer to Section 3 of the Act for

definitions of children and young people.)

Crimes Act 2000

http://www.legislation.nsw.gov.au/viewtop/inforce/

act+66+2007+cd+0+Y/

■ Consent exists only when a person freely and

voluntarily agrees to engage in sexual intercourse.

The law states that a person is unable to give consent

when they were:

– asleep or unconscious

– significantly intoxicated or affected by drugs

– unable to understand what they are consenting to

http://www.legislation.nsw.gov.au/sessionalview/sessional/act/1996-114.pdf

http://www.legislation.nsw.gov.au/sessionalview/sessional/act/1996-114.pdf

http://www.lawlink.nsw.gov.au/vs

http://www.lawlink.nsw.gov.au/vs

http://www.austlii.edu.au/au/legis/nsw/consol_act/hraipa2002370/sch1.html

http://www.legislation.nsw.gov.au/viewtop/inforce/act+66+2007+cd+0+Y/

http://www.legislation.nsw.gov.au/viewtop/inforce/act+66+2007+cd+0+Y/


– intimidated, coerced or threatened

– submitted to the abuse of authority of a

professional or any other trusted person

– unlawfully detained, or held against their will.

■ These laws do not generally apply to children and

vulnerable people who, under the law, cannot be

said to have consented because of their age and

vulnerability.

■ Vulnerable people include children less than 16 years

of age and people with a cognitive impairment.

A person has a cognitive impairment if they require

supervision or social habilitation in connection with

daily life activities, as a result of one or more of the

following:

(a) an intellectual disability

(b) a developmental disorder (including an autistic

spectrum disorder)

(c) a neurological disorder

(d) dementia

(e) a severe mental illness

(f) a brain injury.

Criminal Procedure Act 1986 No 2009 (Part 5 Division 2 – Sexual Assault Communications Privilege)

■ This Act provides specific protections where there are

criminal proceedings or in Apprehended Violence

Order (AVO) matters.

■ Health records are deemed to be privileged when

the consumer receives counselling or mental health

treatment in which confidential communications are

made by the consumer to health staff; this includes

health staff conversations about the consumer to

another person based upon the consumer’s

communications.

■ This legislation applies to any counselling or mental

health treatment received either before or after an

incident of sexual assault.

■ The privilege that may be claimed in district or local

court proceedings can at times be effectively used in

other court jurisdictions arguing that it is not in the

‘public interest’ for the health records to be accessed

by other parties or that it is not relevant to the current

proceedings.

■ Refer to NSW Health Policy on Subpoenas

(PD2010_065).


APPENDIX D

Information about support options for consumers who have experienced sexual assault

If you experience sexual assault or harassment, you can: Report to Police and access medical care and support

You can choose to report right away. The Police will need to gather evidence of the assault, which will include a forensic medical examination. They can support you to access medical care (through the local Sexual Assault Service or your nearest hospital or emergency department) and counselling and can help with protection/ safety needs. They can also support you to make a statement but you don’t have to do this right away if you’re not feeling up to it.

Where possible a full forensic exam is most effective within 72 hours of the assault or within one week.

If you want to report to the Police, you can call 000 or contact your nearest Police station. You can ask to speak to a female officer.

Report to Police, access medical care and support, but request no further legal action

You can choose to report to Police and access medical care, counselling support, and undergo a forensic medical examination (through the local Sexual Assault Service or your nearest hospital or emergency department), but withdraw your complaint at a later time if you feel unable to proceed.


If you want to report to the Police, you can call 000 or contact your nearest Police station. You can ask to speak to a female officer.

Police can also help with protection/safety needs.

Access medical care and forensic exam if undecided about whether to report

You can keep your options open by having a forensic medical examination and asking that the Sexual Assault Service store the evidence (for up to three months) while you decide if you want to proceed with legal action.


You can contact your nearest Sexual Assault Service or go to your nearest hospital or emergency department – contact the Victims Access Line Line on 1800 633 063 or (02) 8688 5511 for referral to your nearest medical care facility where you can access a forensic medical examination.

Access medical care and support and not report assault to Police

You can choose not to report to Police but still get a medical check done and access counselling support from the local Sexual Assault Service.

Medical care can involve dealing with the physical and psychological impact of the assault, as well as any concerns about pregnancy or sexually transmitted infections. Please note that morning after pills are most effective taken within 72 hours of the assault.

You can contact your nearest Sexual Assault Service or go to your nearest hospital or emergency department.

You could also see a general practitioner/ doctor if you don’t want a full forensic exam. Women’s Health Centres, Sexual Health Centres and Family Planning Clinics can also offer medical support/ follow up.

No medical care or reporting, but still access support

You can choose not to report to Police or get a medical check done. This option does not include medical support or legal action.

For counselling support, you can still contact your nearest Sexual Assault Service or go to your nearest hospital or emergency department, the Victims Access Line on 1800 633 063 or (02) 8688 5511.


APPENDIX E

Information about reporting to Police for consumers who have experienced sexual assault

■ Sexual assault is a serious crime

■ A complaint can be made at any time. It does not have to be straight away.

■ You can have forensic evidence taken and decide about reporting later.

■ If the assault happened in the past, or when you were a child, a statement can still be made. Sometimes Detectives

have other information about the offender which may help build a case.

■ When making a complaint you can take a support person as long as that person will not be a witness – the Detectives

can assist in deciding this. You can ask to meet Detectives at another location initially although the statement will be

taken at the Police Station. If walking into the Police Station feels difficult, you can ring the Crime Manager, or ask your

mental health service to ring them, to arrange an easier way to make contact.

■ If an interpreter is needed the Police will arrange this.

■ You can ask to speak to a female Detective and if one is available that will be arranged.

■ If making a formal complaint is too difficult but you would like Police to have information about the crime, an informal

report can be made. This may help in other investigations.

■ You have the right to withdraw a complaint at any time.

■ The Police Duty Officer or Crime Manager will ask basic information and then call a Detective.

■ If the assault was recent Police will, with permission, take you to the nearest sexual assault unit where sexual assault

counselling, medical assistance and the collection of forensic evidence will, with your permission, be arranged.

■ Detectives will determine what investigations will take place after taking your statement. This may take some time and

the Detectives may ask for further information.

■ The investigating Detective will provide their contact details and the case number and keep you, or your nominated

representative, informed of progress. You can ring the Detective for updates, or ask your mental health service to do

this.

■ If the Detective can gather enough evidence, charges will be laid. Sometimes there is not enough evidence and there is

no further action. This does not mean the Police do not believe you – it only means that they cannot prove ‘beyond

reasonable doubt’ that a crime has occurred.

Source: NSW Rape Crisis Centre information sheet ‘Sexual Assault in NSW’

Things to consider when deciding whether to report an incident of sexual assault to police

What will happen when you do report sexual assault to police


APPENDIX F

Example posters on accessing support

Appendix F – Example posters on accessing support

Are you someone with a mental illness that fits into one of the following groups? If you need help and advice about sexual assault or abuse, you can contact the Sexual Assault Service in your locality.

Are you from a Culturally and Linguistically Diverse background? If so, you can also contact:

Community Relations Commission

1300 651 500

Telephone Interpreter Services (24hrs)

13 14 50

Transcultural Mental Health

1800 648 911

Services for Treatment & Rehabilitation of Torture & Trauma Services (STARTTS)

02 9794 1900

<INSERT LOCAL SUBURB> SEXUAL ASSAULT SERVICE 02 <INSERT LOCAL SAS PHONE NUMBER>

An adult sexual assault victim

An adult who was sexually abused as a child

A child or young person under the age of 18 years who has been sexually assaulted or abused

A parent, carer, friend or family of a sexual assault victim


Are you a Koori person with a mental illness that needs information about sexual assault or abuse? If you are an Aboriginal person that needs help and advice about sexual assault or abuse, you can contact the following services.

•Indigenous Women's Legal Centre & Contact Line 1800 39 784•Wirringa Baiya Aboriginal women's Legal Centre, phone 1800 686 587•Aboriginal and Torres Strait Islander Legal Services: www.nwjc.org.au

Sexual Assault Services for Aboriginal & Torres Strait

Islander people

•If you wish to talk to the police about a sexual assault, you can ask to speak with an Aboriginal Community Liaison Officer, who may be located in the Local Area Command. •Police can also contact an Aboriginal Support Person if there is an Aboriginal Support Group or a list of Aboriginal Support persons located in that command.

Aboriginal Community Liaison Officer or

Aboriginal Support Person

•If you are an Aboriginal child or young person or are concerned that a child or young person has been sexually assaulted, you can make a report to the Department of Community Services by contacting the DoCS Helpline , phone 132 111. •If you would like to speak to someone in person, you can go your local Community Services Centre where arrangements can be made for you to talk to an Aboriginal Caseworker.

Department of Community Services or Community

Services Centre

•If you wish to speak to an Aboriginal counsellor in your area, you can contact the Centre for Aboriginal Health on (02) 9391 9502 about the availability of Aboriginal Family Health Workers, and/or Aboriginal sexual assault workers in your area. •NSW health has specially trained counsellors who receive training to respond to the needs of victims of sexual assault.

Centre for Aboriginal Health

•If you are an Aboriginal or Torres Strait Island person who is a victim of violent crime in NSW, like family violence or sexual assault you can call our confidential enquiry line on 188 019 123.• The Witness Assistance Service of the Office of the Director of Public Prosecutions, has some Aboriginal Witness Assistance Officers, who can assist you if you have to go to court. Contact (02) 9285 2502 or 1800 814 534.

Victims Services


APPENDIX G

Sexual Assault Screening Tool

Assure the consumer of confidentiality:

■ Clearly state that any information shared will not be disclosed to the consumer’s carer or family.

■ Know your service’s responsibility regarding reporting sexual assault and take this into consideration when discussing the issue.

■ Assure the consumer that information provided will be kept confidential, except where the assault involves a child or young person, or where the alleged perpetrator is a health worker.

Frame the questions: ■ “So that I can work out the right way to support you while you are with our service, I need to know a bit more detail about your life before you came here, including any experiences you may have had that made you uncomfortable.”

■ “Because sexual assault is so common in many people’s lives, particularly people with mental health issues, we ask all our patients about it.”

■ “I don’t know if this is a problem for you, but many people we see are dealing with a past instance of sexual assault. Some people are reluctant to bring it up, so we always ask the question.”

Ask direct questions: ■ Are you in a relationship with someone who physically or emotionally hurts or threatens you?

■ Has your partner ever forced you to have sex when you didn’t want to or hurt you sexually?

■ Has a friend, a date, or an acquaintance ever pressured or forced you into sexual activities when you did not want them? Touched you in a way that made you uncomfortable? Anyone at home? Anyone at school? Anyone within this service? Any other adult?

Ask about injuries: ■ I notice you have a number of bruises (or other injury) - did someone do this to you?

■ Was it someone from home, like your partner or spouse? Was it someone from within this service?

In a private area

In all mental health settings

WH

ERE As part of routine

admission process or during initial visit

As part of a routine health assessment or taking a health history

During every encounter with a new consumer

Delay until the consumer is stable

WH

EN Combine with any existing violence screening processes

Assure the consumer of confidentiality

Frame the questions to be asked

Ask direct questions

Ask about injuries

Respond to disclosure OR respond to denials

HO

W


Respond to disclosure:

■ Allow the consumer to talk about it – listen non-judgmentally and validate the consumer’s experience by conveying affirming messages that demonstrate sensitivity and compassion.

■ Explore details of the assault (using open-ended questions only), if the consumer is comfortable to do this, and assess the consumer’s mental state.

■ Take steps to ensure the consumer’s safety and secure any evidence if the assault is recent.

■ Offer support and options for dealing with the assault, or set a time to discuss the assault further when the consumer is comfortable to do this.

■ Assess the consumer’s capacity to make decisions regarding reporting the assault or undertaking a forensic medical exam.

■ Organise for the consumer to receive medical care and counselling as required.

Respond to denials: ■ If the consumer denies any assault has taken place, but you still suspect it, let them know your concerns.

■ Make sure you provide the consumer with information about their options if they have been sexually assaulted.

■ Document your concerns in the consumer’s file.


APPENDIX H

Examples of sexualised behaviour by healthcare professionals towards consumers or their carers

ý Asking for or accepting a date

ý Sexual humour during consultations or examinations

ý Inappropriate sexual or demeaning comments, or asking clinically irrelevant questions, for example about their body or

underwear, sexual performance or sexual orientation

ý Requesting details of sexual orientation, history or preferences that are not necessary or relevant

ý Internal examination without gloves

ý Asking for, or accepting an offer of, sex

ý Watching a consumer undress (unless a justified part of an examination)

ý Unnecessary exposure of the consumer’s body

ý Accessing a consumer’s or family member’s records to find out personal information not clinically required for their

treatment

ý Unplanned home visits with sexual intent

ý Taking or keeping photographs of the consumer or their family that are not clinically necessary

ý Telling consumers about their own sexual problems, preferences or fantasies, or disclosing other intimate

personal details

ý Clinically unjustified physical examinations

ý Intimate examinations carried out without the consumer’s explicit consent

ý Continuing with examination or treatment when consent has been refused or withdrawn

ý Any sexual act induced by the healthcare professional for their own sexual gratification

ý The exchange of drugs or services for sexual favours

ý Exposure of parts of the healthcare professional’s body to the consumer

ý Sexual assault

Source: Clear sexual boundaries between healthcare professionals and patients – Information for patients and carers Council for Healthcare Regulatory Excellence, April 2009


APPENDIX I

Responding to a disclosure of sexual assault – key actions

Key action When the assault occurred in the last 7 days

When the assault occurred in the last 6 months

When the assault occurred in the past

Acknowledge and affirm the disclosure

If it is the first disclosure or the consumer has had previous negative experiences of disclosure, regardless of when the assault occurred, this may be a time of crisis for the consumer and staff may need to respond particularly sensitively.

Explore the disclosure

Establish and maintain safety

Secure any evidence

Secure any evidence related to the sexual assault – keep any clothing removed by the victim/survivor that they were wearing at the time of the assault, and secure the location of the assault if possible to prevent any evidence being disturbed.

Offer support and options

A sexual assault can still be reported to the Police when it is not recent and the victim/survivor can still benefit from contact with the local Sexual Assault Service or other relevant counselling and support service.

Assess capacity to make informed decisions

Organise medical care

It is important that victims of sexual assault are offered medical assistance to treat any physical or psychological injuries, regardless of whether the assault was recent or occurred some time ago.

Consumers who were sexually abused as children, or in other settings, may be retraumatised when they enter a new facility, or by events at a facility. Mental health staff should note and be sensitive to ‘triggers’ in their work with consumers that may cause retraumatisation.


Step Action Information

1 Acknowledge and affirm the disclosure

Be non-judgemental, compassionate and understanding when a consumer discloses their experience of sexual assault or harassment and respond promptly, in accordance with the Sexual Safety of Mental Health Consumers Guidelines, whether the assault occurred prior to or after the consumer’s admission.

2 Explore the disclosure Provide the consumer with a safe, quiet, private space and gently encourage them to provide information about the assault. Ensure an assessment of the consumer’s clinical mental state is undertaken within 24 hours in an acute inpatient setting and within 48 hours in all other settings before proceeding with next steps.

3 Establish and maintain safety Assess whether the consumer is in current danger and the need for special accommodations to make the consumer feel safe, being mindful that it is the alleged perpetrator and not the consumer who has been assaulted that should be moved from the facility if required, unless the consumer who has disclosed the assault specifically requests otherwise or there are other extenuating circumstances.

4 Secure any evidence Keep any clothing worn by the consumer at the time of the assault, ensure only the consumer handles these clothes, and secure the location of the assault if possible along with any CCTV footage of the area in which the incident occurred.

5 Offer support and options Provide the consumer with advice and information regarding their options (Appendix D of the Sexual Safety of Mental Health Consumers Guidelines) so they can decide how they want to proceed. The consumer’s wishes regarding how to proceed must be respected unless legislatively prohibited or they lack the capacity to make an informed decision (see Step 6).

6 Organise medical care Encourage the consumer to seek immediate medical care to identify and treat any physical injuries and to discuss issues such as the risk of infection or pregnancy. Offer counselling as required and ensure consent is obtained for any forensic exam.

7 Assess capacity to make informed decisions

This assessment will need to include an evaluation of the consumer’s capacity to understand their options, process and communicate information and effectively exercise their rights. If they are assessed as not having the capacity to make an informed decision regarding their options, any such decision should be delayed if possible until the consumer’s capacity is restored. Alternatively, urgent application can be made for a Guardian to make some decisions.


APPENDIX J

Responding to a disclosure of recent sexual assault – quick checklist

Issues to be considered Yes No Action required/taken Date action taken

Is the consumer in current danger?

Do special accommodations need to be made to make the consumer feel safe?

Has any evidence related to the assault been secured?

Does the consumer want a member of their family or their carer informed?

Does the consumer want to report the assault to the Police?

Does the consumer want to talk to a Sexual Assault Service or other counselling service?

Has the consumer been assessed regarding their capacity to make an informed decision in relation to their assault?

Does the consumer have acute injuries that need medical attention?

Does the consumer want or need a forensic exam to be performed?

If the assault happened within the past 120 hours, and the consumer is female, do they want or need emergency contraception?

Does the consumer want or need prophylaxes for HIV or other sexually transmitted infections?

Does the consumer want or need follow-up care, for either physical or psychological injuries?


APPENDIX K

Follow up medical exams required when a person has been sexually assaulted

Follow-up medical exams are recommended at 2 weeks, 3 months and 6 months post assault. The local Sexual Assault

Service can organise this, but if the consumer does not wish to involve anyone outside of the mental health service, staff

will need to ensure these exams take place.

The 2-week follow-up exam – clinician will need to:

■ Examine any injuries for proper healing.

■ Photograph injuries if indicated (i.e. to document healing, comparisons in court). This should not include injuries to the

genital area.

■ Check that the consumer has completed the course of any medications given for STIs.

■ Obtain cultures and draw blood to assess STI status, especially if prophylactic antibiotics were not given at the

initial visit.

■ Discuss results of any tests performed.

■ Test for pregnancy if indicated. If pregnant, advise about options.

■ Remind consumers to return for their hepatitis B vaccinations in 1 month and 6 months, other immunisations as

indicated, and HIV testing at 3 and 6 months or to follow-up with their usual health care provider.

■ Make follow-up appointments.

■ Assess the consumer’s emotional state and mental status, and encourage the consumer to seek counselling if they have

not yet done so.

The 3-month follow-up exam – clinician will need to:

■ Test for HIV. Make sure that pre- and post-testing counselling is available or make the appropriate referral. Assess

pregnancy status and provide advice and support.

■ Discuss results.

■ Draw blood for syphilis testing if prophylactic antibiotics were not given previously.

■ Assess consumer’s emotional state and mental status and encourage the consumer to seek counselling if they have not

yet done so.

The 6-month follow-up exam – clinician will need to:

■ Test for HIV. Make sure that pre- and post-testing counselling is available or make an appropriate referral.

■ Discuss results.

■ Administer the third dose of the hepatitis B vaccine.

■ Assess the consumer’s emotional health and refer as necessary.

The above information is drawn from the World Health Organisation 2003 Guidelines for medico-legal care for victims of sexual violence, WHO, Geneva


APPENDIX L

Reporting process for an incident of sexual assault

Internally

■ To the Team Leader/Nursing Unit Manager, who must inform the Senior Manager.

■ Through the Reportable Incident Brief (RIB) system – RIB must be submitted within 24 hours when:– the alleged perpetrator is a staff member; or– the consumer who has been assaulted is under 16 years of age; or – the consumer who has been assaulted is over 16 but under 17 years of age and is in a care relationships with the

alleged perpetrator.

■ Through the Root Cause Analysis (RCA) investigation process.

Externally

To the NSW Police Force when:– the consumer requests this and an assessment of the consumer’s clinical mental state does not preclude this as a

relevant step;– the alleged perpetrator is a staff member; or– the consumer is under 16 years of age; or– the consumer is over 16 but under 18 years of age and in a care relationship with the alleged perpetrator; or the

consumer does not have the capacity to make an informed decision, and the senior clinician has a duty of care to formally report the assault.

To the Child Protection Helpline (13 36 27) when:– the consumer is a child under 16 years of age. The Helpline must also be contacted if the consumer is a child at risk

of significant harm (which includes when they have had consensual sexual intercourse); or– the consumer is over 16 but under 17 years of age and in a care relationship with the alleged perpetrator.


APPENDIX M

Information about Managing Disinhibited Behaviour

Talk about behaviour Educate and inform family, friends, staff about the behaviour and strategies to manage it.

■ Talk to the person about their behaviour and what you expect.■ Let them know if behaviour is not appropriate – if they don’t know, they can’t change it.■ Let them know how the behaviour makes you feel e.g. ‘I feel uncomfortable when …’■ Let other people know what strategies to use.

Provide feedback about behaviour

Provide the person with frequent, direct and clear feedback. Feedback should:

■ Be immediate and early■ Be direct■ Be concrete and describe the behaviour■ Give direction■ Be consistent■ Not reinforce/encourage behaviour■ Help the person to learn■ Not be demeaning or humiliating■ Not impose your own values

Manage the environment ■ Try to predict situations where the behaviour is more likely to happen.■ Work out strategies ahead of time to cope with the behaviour.■ Restrict any opportunity to engage in inappropriate behaviour (planning, proximity,

opportunity, means)■ Limit any ‘at risk’ social activities e.g .crowded clubs or pubs or where alcohol is being

consumed.■ Provide cues re behaviour – what the person should/should not do – before, during, and

after social activities.■ Limit the amount of time a person spends in each situation.■ Provide alternative activities e.g. small groups verses large groups.■ Keep a comfortable distance so the person cannot touch, grab or get too close.

Provide supervision and structure

■ Provide one-to-one support and supervision in any ‘at risk’ situations.■ Provide cues and prompts about appropriate or inappropriate behaviour.■ Redirect, distract or divert the person e.g. more appropriate topics of conversation, or

change the activity or task.

Plan ahead If a person has a history of severe disinhibited sexual behaviour (exposure, masturbation in public, or sexual assault), it is essential that you plan ahead regarding personal safety.

Consider:

■ having two people provide care■ limiting home visits■ supervising children■ limiting access to certain environments

In the person’s home:

■ Always visit with another person or make sure someone knows you are there when you visit.■ Take a mobile phone with you, and carry it at all times.■ Have your car keys in your pocket.■ Get familiar with the home, so you know where the doors are located.■ Keep a comfortable distance. For example, sit across a table, sit close to the door.

Adapted from the State of Queensland (Queensland Health) 2007 Acquired Brain Injury Outreach Service


References

Abuse and Violence: Working with our patients in general

practice (3rd edition) (2008). South Melbourne: The

Royal Australian College of General Practitioners.

Acquired Brain Injury Outreach Service (2011). What is

disinhibited and inappropriate sexual behaviours?

Retrieved August 2011, from Queensland Health:

http://www.health.qld.gov.au/abios/

Agar, K, Read, J, Bush, J.M. (2002). ‘Identification of

abuse histories in a community mental health

centre: The need for policies and training’. Journal

of Mental Health, vol. 11, no. 5, pp. 533-543.

Burgess AW, Holmstrom LL. Rape trauma syndrome.

Am J Psychiatry 1974: 131:981–6.

Carmody, M. (2003). Sexual Ethics and Violence

Prevention. Social & Legal Studies, 199-216.

Carmody, M., Evans, S., Krogh, C., Flood, M., Heenan,

M., & Ovenden, G. (2009). Framing best practice:

National Standards for the primary prevention of

sexual assault through education, National Sexual

Assault Prevention Education Project for NASASV.

University of Western Sydney, Australia.

Carmody, M., & Willis, K. (2006). Developing Ethical

Sexual Lives: Young People, Sex and Sexual Assault

Prevention. Sydney: University of Western Sydney,

Social Justice Social Change Research Centre.

Cook, B., David, F., Grant, A. (2001). Sexual Violence in

Australia. Australian Institute of Criminology.

ISBN 0 642 24205 4.

Crome, S. (2006). Male survivors of sexual assault and

rape (ACSSA Wrap No. 2). Melbourne: Australian

Centre for the Study of Sexual Assault.

Deegan, P. E. (2001). Human Sexuality and Mental Illness:

Consumer Viewpoints and Recovery Principles. USA.

Department of Health. Women’s Mental Health: Into the

Mainstream, Strategic Development of Mental

Health Care for Women. (2002). Available at: www.

dh.gov.uk/assetRoot/04/07/54/80/04075480.pdf

Disability Discrimination Legal Service. (2003). Beyond

Belief, Beyond Justice: The difficulties for victim/

survivors with disabilities when reporting sexual

assault and seeking justice. Melbourne.

Evans I 2007, Battle-scars: Long-term effects of prior

domestic violence, Melbourne: Centre for Women’s

Studies and Gender Research, Monash University.

Ford, E., Rosenberg, M., Holsten, M., & Boudreaux, T.

(2003). Managing Sexual Behavior on Adult Acute

Care Inpatient Psychiatric Units. PSYCHIATRIC

SERVICES, 54 (3), 346-350.

Golding, J.M. (1999) ‘Intimate partner violence as a risk

factor for mental disorders: a meta-analysis’, Journal

of Family Violence, vol. 14, no. 2: 99–132.

Goodfellow, J., & Camilleri, M. (2003). Beyond Belief,

Beyond Justice: The difficulties for victim/survivors

with disabilities when reporting sexual assault and

seeking justice. Final report of stage one of the

Sexual Offences Project. Melbourne: Disability

Discrimination Legal Service.

Goodman, L.A.; Rosenberg, S.D.; Mueser, K.T.; and

Drake, R.E. Physical and sexual assault history in

women with serious mental illness: Prevalence,

correlates, treatment, and future research directions.

Schizophrenia Bulletin, 23(4):685-696, 1997.

Goodman, L.A.; Salyers, M.P.; Mueser, K.T.; Rosenberg,

S.D.; Swartz, M.; Essock, S.M.; Osher, F.C.; and

Butterfield, M.I. Recent victimization in women and

men with severe mental illness: Prevalence and

correlates. Journal of Traumatic Stress, 14:615-632,

2001.

http://www.health.qld.gov.au/abios/

http://www.dh.gov.uk/assetRoot/04/07/54/80/04075480.pdf

http://www.dh.gov.uk/assetRoot/04/07/54/80/04075480.pdf


Goodman, L.A.; Thompson, K.M.; Weinfurt, K.; Corl, S.;

Acker, P.; Mueser, K.T.; and Rosenberg, S.D.

Reliability of reports of violent victimization and

PTSD among men and women with SMI. Journal of

Traumatic Stress, 12:587-599, 1999.

Havig, K. (2008, January). The Health Care Experience of

Adult Survivors of Child Sexual Abuse – a

systematic review of evidence on sensitive practice.

Trauma, Violence & Abuse, pp. 19-33.

Jennings, A. (2004). The Damaging Consequences of

Violence And Trauma: Facts, Discussion Points, and

Recommendations for the Behavioural Health

System. Alexandria, VA: National Association of

State Mental Health Program Directors, National

Technical Assistance Center for State Mental Health

Planning.

Kessler, R.C.; Crum, R.M.; Warner, L.A.; Nelson, C.B.;

Schulenberg, J.; and Anthony, J.C. Lifetime

co-occurrence of DSM-III-R alcohol abuse and

dependence with other psychiatric disorders in the

national comorbidity survey. Archives of General

Psychiatry, 54:313-321, 1997.

Kessler, R.C.; Sonnega, A.; Bromet, E.; Hughes, M.; and

Nelson, C.B. Posttraumatic stress disorder in the

national comorbidity survey. Archives of General

Psychiatry, 52:1048-1060, 1995 Inappropriate

Sexual Behavior in Long-Term Care.

Making choices Keeping safe Policy and Practice

Guidelines on relationships and sexual wellbeing

when working with people with learning disabilities.

(2004) UK. Lothian National Health Service.

Mental Health ACT. (2009, January). Promotion of Sexual

Safety/Prevention and Management of Sexual

Assault in Bed Based Services Policy. ACT, Australia.

McGee H, Garavan R, deBarra M, Byrne J, Conroy R

(2002). The SAVI Report. Sexual Abuse and

Violence in Ireland. A national study of Irish

experiences, beliefs and attitudes concerning sexual

violence. Dublin: Liffey Press, 2002.

Mueser, K.T.; Goodman, L.B.; Trumbetta, S.L.; Rosenberg,

S.D.; Osher, F.C.; Vidaver, R.; Auciello, P.; and Foy,

D.W. ‘Trauma and posttraumatic stress disorder in

severe mental illness’. Journal of Consulting and

Clinical Psychology, 66:493-499, 1998.

National Disability Services WA. (2008). Guidelines for the

prevention and management of sexual abuse for

disability service providers in Western Australia –

An Information and Policy Resource.

‘National Executive Training Institute (NETI). (2005).

Training Curriculum for Reduction of Seclusion and

Restraint. Draft curriculum manual. Alexandria, VA:

National Association of State Mental Health

Program Directors (NASMHPD), National Technical

Assistance Center for State Mental Health Planning

(NTAC).

National Sexual Violence Resource Center. (2011).

Assessing Patients for Sexual Violence – A Guide for

Health Care Providers.

Paul Kettl, M. (2008). Inappropriate Sexual Behaviour in

Long-Term Care. Annals of Long-Term Care.

Petrak, J. (2002). The psychological impact of sexual

assault. In J. Petrak & B. Hedge (Eds.), The Trauma

of Sexual Assault: Treatment, Prevention and

Practice. West Sussex: John Wiley & Sons.

Powell, A. (2007). Sexual pressure and young people’s

negotiation of consent. ACSSA Aware Newsletter,

14, 8–16. Retrieved 31 July 2008.

From http://www.aifs.gov.au/acssa/pubs/newsletter/

n14.html

Powell, S. M. (2008). Sexual assault and adults with a

disability – enabling recognition, disclosure and a

just response. ACSSA Issues, No. 9.

Registered Nurses’ Association of Ontario – Nursing Best

Practice Guidelines Program. (2005). Woman

Abuse: Screening, Identification and Initial

Response. Toronto: Registered Nurses’ Association

of Ontario.


Royal Australian College of General Practitioners – Quality

Care and Research Unit. (2008). Abuse and

violence: Working with our patients in general

prctice (3rd edition).

Simpson GK. & Orchison R (2006). Sexuality after

traumatic brain injury: issues and strategies.

In: Introduction to traumatic brain injury: a training

kit. http://www.tbistafftraining.info

Stepakoff, S. (1998). Effects of sexual victimization on

suicidal ideation and behaviour in U.S. college

women. Suicide and Life-Threatening Behavior,

28(1), 107–126.

Taft, A. (2003), ‘Promoting women’s mental health:

The challenges of intimate/domestic violence

againstwomen’, Issues Paper 8, Australian Family

and Domestic Violence Clearinghouse, Sydney.

Available: www.adfvc.unsw.edu.au/PDF%20files/

Issues_Paper_8.pdf

Teasdale,B. (2009) ‘Mental Disorder and Violent

Victimization’, Criminal Justice and Behaviour,

Issue 36: 513-535.

Urbis Keys Young for the Office of the Status of Women,

Department of the Prime Minister and Cabinet.

(2004). National Framework for Sexual Assault

Prevention. ACT: Commonwealth of Australia.

Victorian Women and Mental Health Network. (2009).

Increasing Safety and Gender Sensitivity in mixed

sex psychiatric units.

Wahl, J. (2008). Sexuality in Long Term Care Homes –

the Legal Issues. Toronto, Ontario, Canada.

Warner, J., Pitts, N., Crawford, M. J., Serfaty, M.,

Prabhakaran, P., & Amin, R. (2004). Sexual activity

among patients in psychiatric hospital wards. Journal

of the Royal Society of Medicine, 97, 477-479.

Woman Abuse: Screening, Identification and Initial

Response – Nursing Best Practice Guideline. (2005).

Registered Nursing Association of Ontario, CAN.

The Women’s Health Council. (2007). A Guide to

Creating Gender-Sensitive Health Services.

The Women’s Health Council. Women’s Mental Health:

Promoting a Gendered Approach to Policy and

Service Provision. Dublin.

Women’s Centre for Health Matters Inc. (2009). WCHM

Position Paper on Gender Sensitive Mental Health

Service Delivery. Canberra.

World Health Organization, International Consortium of

Psychiatric Epidemiology. 2000. Crossnational

comparisons of mental disorders. Bulletin of the

World Health Organization, 78: 413-426.

World Health Organization (2006). Gender disparities in

mental health. Available at:

www.who.int/mental_health/media/en/242.pdf.

Accessed 9 July 2012.

http://www.who.int/mental_health/media/en/242.pdf

Disclaimer

While every effort has been made to ensure the accuracy and reliability of the information in this document at the time of publication, it is the

responsibility of users to check the currency of key documents, policies and procedures.

Acknowledgements

NSW Health would like to thank all members of the Working Group and the Reference Group, and a range of key stakeholders, who provided

support, guidance, advice and feedback during the development of the Sexual Safety of Mental Health Consumers Guidelines.

The NSW Ministry of Health extends special thanks to:

AIDS Council of NSW Inc (ACON)

Association of Relatives and Friends of the Mentally Ill (ARAFMI) NSW

Assoc. Prof Julian Trollor

Chair, Intellectual Disability Mental Health, School of Psychiatry

Head, Department of Developmental Disability Neuropsychiatry

University of New South Wales

Education Centre Against Violence (ECAV)

Ministry of Health, Centre for Aboriginal Health

Ministry of Health, Mental Health Program Council Consumer Sub-committee

Ministry of Health, Mental Health Clinical Advisory Council

Ministry of Health, MH-Kids, Mental Health and Drug and Alcohol Office (MHDAO)

Ministry of Health, Primary Health and Community Partnerships Branch

Ministry of Health, MHDAO, Older Persons Mental Health

NSW Consumer Advisory Group – Mental Health (Inc) (NSW CAG)

NSW Health Local Health District (LHD) mental health clinicians and staff

NSW Health Sexual Assault Services

NSW Police Force

Transcultural Mental Health Centre

SHPN (MHDAO) 120421

Sexual Safety of Mental Health Consumers Guidelines · Sexual Safety of Mental Health Consumers...

Documents

Transcript of Sexual Safety of Mental Health Consumers Guidelines · Sexual Safety of Mental Health Consumers...